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THE STATE 
OF THE 
SAFETY 
NET 2014 
Healthcare Reform 
and the Safety Net 
PHOTO: MARGARET MOLLOY 
 Clínica Monseñor Oscar A. Romero, 
Los Angeles, California
AT LEAST 
10,000 HEALTH FACILITIES 
50 STATES 
24 MILLION PATIENTS 
 35% LACK INSURANCE 
72% ARE BELOW POVERTY LEVEL 
4 // 
INTRODUCTION 
6 // 
TERMINOLOGY 
8 // 
THE PROVIDERS 
12 // 
THE PATIENTS 
18 // 
THE CONDITIONS 
24 // 
THE COMMUNITIES 
30 // 
BACKGROUND 
32 // 
METHODOLOGIES 
WILLIAM VAZQUEZ FOR ABBOTT FUND 
CONTENTS 
2 // THE STATE OF THE SAFETY NET 2014 // CONTENTS DirectRelief.org/USA
PHOTO: MARGARET MOLLOY 
"We’re excited because we want 
people to have access. That’s what 
our mission is; health care is a right 
not a privilege, but we just need to 
make sure that we’re financially 
healthy as well." 
—ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, 
WILLIAM F. RYAN COMMUNITY HEALTH CENTER, NEW YORK, NY 
 Clínica Monseñor Oscar A. Romero, 
Los Angeles, California 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // CONTENTS // 3
PHOTO: CHASS 
The Affordable Care Act (ACA) is a sea change in the U.S. healthcare system. In 
the context of that change, the critical role of nonprofit safety-net healthcare 
providers warrants particular attention. Providing care to more than 24 million people, 
these health centers and clinics are on the front lines of treating those who are most 
in need, without insurance, and living in poverty. This report, as in past reports, aims 
to provide a current overview of these providers. In this edition we have also added a 
snapshot of their perspectives on the ACA. Interviews were conducted over the past year 
with an array of providers—large and small facilities, free clinics and Federally Qualified 
Health Centers, providers in rural and urban environments, in states that have expanded 
Medicaid and states that have opted out. The goal was to understand the pending impact 
of one of the most sweeping laws our nation has seen on the providers that are, in many 
ways, most important to reaching disadvantaged communities. Perhaps, not surprisingly, 
there is a wide range of views and feelings among safety net health providers. Four 
common threads recurred. 
TAKEAWAYS 
1. At the highest level, 
all providers, regardless of 
location, size, or facility type, underscored 
that for the foreseeable future the need 
for charitable health care will remain. The 
need for charitable care is perhaps most 
obvious in the states that have chosen not 
to expand Medicaid, which will under any 
immediate scenario continue to have higher 
levels of people who are uninsured than 
in the expansion states. Beyond this very 
obvious need there will continue to be gaps 
in coverage for immigrants (undocumented 
and otherwise) and those who will 
otherwise fall through the cracks. 
2. As safety net providers have 
long known, having insurance is 
not the same as having access to a high-quality 
health care provider. Great unease 
exists throughout the safety net about 
demand for services among the newly 
insured, dramatically outpacing the supply 
of health facilities and health professionals. 
INTRODUCTION 
 Community Health and Social 
Services, Detroit, Michigan 
4 // THE STATE OF THE SAFETY NET 2014 // INTRODUCTION DirectRelief.org/USA
1. At the highest level, 
all providers, regardless 
of location, size, or facility type, 
underscored that for the foreseeable 
future the need for charitable health 
care will remain. 
2. As safety net providers 
have long known, having 
insurance is not the same as having 
access to a high-quality health care 
provider. 
3. Geography matters — 
one cannot talk about the 
Affordable Care Act without taking 
about differences of place. 
4. Safety net providers 
consistently pointed out 
that we are only at the very beginning 
stages of the momentous changes yet 
to come. 
3. Geography matters 
– one cannot talk about 
the Affordable Care Act without 
taking about differences of place. 
Vast unevenness exists in the law’s 
application, most obviously again in the 
split between Medicaid expansion and 
non-expansion states. But that geographic 
unevenness is amplified by unevenness 
in the functionality of the new insurance 
exchanges (federal and state), in the 
public health and economic conditions of 
different areas of the country, and even in 
the differential risk of natural disasters in 
places where the law’s outcomes are as 
yet unknown. 
4. Safety net providers 
consistently pointed out that 
we are only at the very beginning stages 
of the momentous changes yet to come. 
Change of this scale cannot happen 
overnight. The shifting landscape of 
insurance coverage and health providers 
that treat low income patients is creating 
a more complex safety net; the provision 
of charitable care must rise to meet the 
challenge of that additional complexity. 
As people receive coverage they in some 
cases had never had before in their lives, 
it is a new experience for them and will 
take time to adjust. While the ACA is a 
national law, the practice of US health 
care, particularly for the most vulnerable 
parts of our population, is changing on a 
community by community basis. 
As the report details, the 
perspectives of these providers on the 
implications and outcomes of the ACA have 
much to do with where they exist, what 
type of facility they are, and what sort of 
population they serve. The environments 
range dramatically – from states that have 
moved forward with Medicaid expansion 
compared with states that have not, some 
of which already have significantly greater 
disease burdens and risks than others. 
Facilities range widely from larger and 
more established health centers with staff 
that have extensive experience assisting 
with insurance enrollment, as compared 
to smaller, volunteer run free clinics with 
minimally comparable background. Still, 
though their environments may differ, 
their purpose does not: ensuring that 
everyone, regardless of their ability to pay 
or their personal background, have access 
to safe, high-quality healthcare. 
Direct Relief is the sole nonprofit 
licensed to distribute prescription 
medicines in all 50 states and runs the 
largest U.S. charitable medicines program 
through a network of more than 1,200 of 
these providers in all 50 states. A unique 
perspective is afforded from our close, 
daily interaction to understand these 
providers' circumstances, needs, interests, 
and concerns and, in turn, mobilize and 
deliver charitable resources efficiently. 
One thing that our interactions with safety 
net providers has consistently shown us 
is that the most informed and thoughtful 
views are not always delivered in the 
loudest voice or even heard at all over the 
din of vigorous debate. These leaders' 
voices, experienced and reflective of the 
breadth of circumstances that exist on 
the frontlines of the healthcare safety net, 
describe the strong influence of place and 
the differences in circumstances that exist. 
For the millions of people that depend on 
America's nonprofit healthcare safety net, 
we hope these voices will be heard much 
more in the years to come. 
“ TRYING TO PROVIDE 
FOR UNINSURED 
PATIENTS—WE’RE 
GOING TO KEEP 
DOING THAT UNTIL 
WE KNOW THERE 
IS AN ANSWER. WE 
ARE GOING TO KEEP 
DOING WHAT WE’RE 
DOING AND MAKING 
A WAY TO PROVIDE 
GOOD QUALITY CARE 
FOR UNINSURED 
PATIENTS.” 
—Jane Calhoun, VP Medical Affairs 
& Clinical Director, Delta Health 
Alliance, Stonesville, MS 
4 TAKEAWAYS 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // INTRODUCTION // 5
> Affordable Care Act (courtesy of the Kaiser Family Foundation) – Requires most U.S. 
citizens and legal residents to have health insurance. Creates state-based American 
Health Benefit Exchanges through which individuals can purchase coverage, with 
premium and cost sharing credits available to individuals/families with income between 
133-400% of the Federal Poverty Level and creates separate Exchanges through 
which small businesses can purchase coverage. Requires employers to pay penalties 
for employees who receive tax credits for health insurance through an Exchange, 
with exceptions for small employers. Impose new regulations on health plans in the 
Exchanges and in the individual and small group markets. Expands Medicaid to 133% of 
the Federal Poverty Level. 
> Direct Relief Partner – a community clinic, Federally Qualified Health Center, or free 
or charitable clinic that was vetted and approved to be part of the Direct Relief Partner 
Network. 
> Direct Relief Partner Network – the network of more than 1,200 community clinics, 
Federally Qualified Health Centers, and free or charitable clinics that Direct Relief 
currently supports with donations of free medicine and medical supplies. 
> Federal Poverty Level (FPL) – the set minimum amount of gross income that a family 
needs for food, clothing, transportation, shelter, and other necessities as determined by 
the Department of Health and Human Services. FPL varies according to family size. The 
number is adjusted for inflation and reported annually in the form of poverty guidelines. 
> Medicaid – a U.S. government program—financed by federal, state, and local funds— 
that provides health coverage for lower-income people, families and children, the elderly, 
and people with disabilities. 
TERMINOLOGY 
> Safety Net – the network of nonprofit provider agencies that deliver health services to 
vulnerable populations experiencing financial, cultural, linguistic, geographic, or other 
obstacles to accessing adequate health care. The nation’s healthcare safety net includes 
more than 10,000 clinical sites providing comprehensive, culturally-competent health 
services to more than 24 million people regardless of their ability to pay. 
TYPES OF SAFETY-NET FACILITIES 
> Community Clinic – a nonprofit provider agency that treats anyone regardless of 
ability to pay, but generally charges patients on a sliding fee scale. 
> Federally Qualified Health Center (FQHC) – public and private nonprofit 
healthcare providers located in medically underserved areas that treat anyone 
regardless of ability to pay, and meet certain federal criteria under the Health 
Center Consolidation Act (Section 330 of the Public Health Service Act). There are 
1,202 FQHCs operating over 8,000 sites in 2013 that treated 21.7 million people 
across the United States, of whom 7.6 million lacked health insurance. 
> Free Clinic – a nonprofit, usually volunteer-based provider facility that treats 
anyone regardless of ability to pay, typically free of charge or with a nominal 
donation for services. An estimated 1,200 free clinic operate across the United 
States. 
> Look-Alike – an organization that meets the eligibility requirements of Section 
330 of the Public Health Service Act, but does not receive federal grant funding. 
Look-Alikes receive many of the same benefits as FQHCs, including enhanced 
Medicare and Medicaid reimbursement, and eligibility to purchase prescription 
and non-prescription medications at a reduced rate. There were 100 Look-Alikes 
in 2013 that treated 1.0 million people across the United States, of whom 329,000 
lacked health insurance. 
6 // THE STATE OF THE SAFETY NET 2014 // TERMINOLOGY DirectRelief.org/USA
"PLACES LIKE US THAT ARE SMALL, 
TOTALLY FREE, AND DON’T PARTICIPATE 
IN GOVERNMENT MONEY ARE GOING TO BE 
THE NEW SAFETY NET 
FOR PEOPLE FALLING THROUGH THE NET OF 
THE AFFORDABLE CARE ACT." 
—RICHARD GIBBS, PRESIDENT AND CO-FOUNDER, 
SAN FRANCISCO FREE CLINIC, SAN FRANCISCO, CA 
 Venice Family Clinic, Venice, California 
PHOTO: MARGARET MOLLOY 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // TERMINOLOGY // 7
 Community Health and Social 
Services, Detroit, Michigan 
THE PROVIDERS 
Safety Net Voices and the Affordable Care Act 
PHOTO: CHASS 
8 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS DirectRelief.org/USA
An interview with Nicole Lamoureux, 
Executive Director, National Association 
of Free and Charitable Clinics 
DIRECT RELIEF: Can you provide some 
background into your association and free 
clinics? 
NICOLE LAMOUREUX: 
The National 
Association 
of Free and 
Charitable Clinics 
is the only national 
organization that 
is organized and 
developed to 
work with free clinics in the communities 
they serve. Our mission is to broaden 
access to affordable health care for the 
medically underserved by increasing public 
awareness, promoting volunteerism, and 
supporting and advocating for the nation’s 
Free and Charitable Clinics as we work 
together to build a healthy America, one 
patient at a time. Many people do not 
realize that there are approximately 1,200 
free or charitable clinics throughout the 
nation, who, since the 1960s, have been 
filling in the gap for those who fall through 
the cracks in our current healthcare 
system. 
Our clinics believe in giving a hand 
up, not a hand out. We activate at the 
grass roots level, not at the government 
level. What sets us apart from our other 
counterparts in the safety net arena 
is that we receive little to no state or 
federal funding and we are not considered 
Federally Qualified Health Centers. Our 
clinics rely very heavily on the generosity of 
individual donors, foundations, and grants 
as funding sources, and we utilize a staff 
and volunteer model to provide health care 
to those in our communities who need it 
the most. 
DIRECT RELIEF: As the legislation has begun 
to roll out, how do you see the initial impact 
affecting free clinics? 
NICOLE LAMOUREUX: The first thing that I 
stress when I’m speaking to people is 
one of the most common misconceptions 
about how the United States will look after 
the full implementation of the ACA is that 
there will no longer be a need for free or 
charitable clinics any longer. 
The Affordable Care Act was never 
designed to be a universal healthcare 
option, a public option – an option where 
every single person in America was given 
an insurance card. Rather, it was to lower 
the barriers of health affordability for many 
people in the country. We know that this 
is not a public option, so that means that 
everyone is not going to have access. So 
as we’re looking at where the ACA is going 
to go in the future, free clinics are dealing 
with a couple of different issues when it 
comes to our patients. 
There are clinics who are located in 
states who have not expanded the Medicaid 
program. There are about 26 of those 
states across the country. Those states 
may or may not decide to have a model 
that is a different way to expand Medicaid 
than the one that was outlined in the bill. 
But currently in the states where there is 
no expansion of Medicaid, the patients will 
not have access to any of the subsidies or 
any of the programs that those living in 
expansion states do. 
As we’re looking at patients across 
the country, first and foremost, there 
is important education going on. If you 
think about it, having health insurance 
is confusing for those of us who have 
had health insurance our entire lives, 
never knowing what form to fill out, or 
whether your doctor is in-network or not 
in-network, if you are self-insured or your 
employer offers your healthcare plans. 
This is confusing for people who have had 
health insurance, imagine being someone 
who has never had health insurance 
before and you have no idea how to fill out 
what forms are needed for you or where 
you can go to the doctor. And then, even 
more so, imagine if you are a person who 
is eligible for the health insurance plans, 
but you have a job that doesn’t allow you 
to go to the doctor between 9:00 and 5:00. 
One of the things that Free and Charitable 
Clinics can offer as part of the safety net is 
sometimes our hours are different. They 
are the non-traditional hours that allow 
people to go to the clinics to get the care 
that they need and continue to be working. 
DIRECT RELIEF: Is there a difference for 
free clinics in the states that will expand 
"CHARITABLE CARE WILL REMAIN A 
VIABLE MODEL AS LONG AS WE DON’T 
HAVE UNIVERSAL HEALTHCARE. THERE 
WILL STILL BE PEOPLE WHO FALL 
THROUGH THE CRACKS. THAT’S OUR 
MANTRA—FILLING THE GAPS AND 
HELPING PEOPLE WHO FELL THROUGH 
THE CRACKS." 
—Beth Houghton, Executive Director, 
St. Petersburg Free Clinic, St. Petersburg, FL 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS // 9
Medicaid and in states that won’t expand 
Medicaid? 
NICOLE LAMOUREUX: Clinics in states that are 
not expanding their Medicaid programs 
are definitely going to continue working 
in the same way that they have in the last 
couple of years, with an eye towards the 
future and what other clinics are doing 
in other locations. The reality of not 
expanding Medicaid means that you have 
a very similar patient base to what you 
have today, as opposed to those states that 
have expanded their Medicaid programs 
and their patient demographics may look a 
little different moving forward. 
However, I think what you are finding 
more clinics doing is looking at how to 
best serve the needs of their community. 
And what we are finding is we can look 
at clinics who have decided that it is the 
best interest of their community and their 
patient base to transition into a Federally 
Qualified Health Center role, where they 
will still serve the uninsured, but be able 
to take some funding from the federal 
government. Then we look at some of our 
clinics who have decided to take more 
of a charitable clinic role where, at this 
point in time, they are asking patients 
for a $5 payment towards their services, 
instead of free. We also then have clinics in 
states, regardless of whether Medicaid is 
expanding, who have said, “You know what? 
We need to be a hybrid clinic. We need to 
have an entire free clinic side of things, 
but we also need to start accepting some 
Medicaid patients as well.” Then I think 
you’re also looking at clinics who have 
said, “For right now, where we are in our 
communities and what we’re doing, we’re 
just going to remain free clinics.” 
That’s probably one of the most 
beautiful things about Free and Charitable 
Clinics is that we truly can be community 
built and grassroots built. We’re finding 
that clinics are looking at how to best serve 
their community and does the business 
model need to change, and how does that 
impact the mission of my organization 
all at one time? It’s a real growth and 
opportunity time for us, along with a 
challenge. 
DIRECT RELIEF: What are some of the 
opportunities or challenges the ACA 
presents free clinics? 
NICOLE LAMOUREUX: Well, I think definitely 
the opportunity that we see, and that we 
are hoping by telling the story of our clinics 
across the country and the amazing work 
that they do on a daily basis, we’re hoping 
to highlight how critical we are to the 
nation’s safety net. We are an essential 
piece to the safety net and that’s an 
opportunity, to tell the story of who’s left 
behind when it comes to the Affordable 
Care Act, the stories of the patients that 
are not going to receive coverage. 
Some of the challenges that we are 
addressing are not just for our clinics, 
but also for our patients: Whether or not 
people understand what the Affordable 
Care Act is, if someone gets an insurance 
card in their pocket, will there be a flooded 
healthcare system? Will there be a doctor 
to accept their health insurance? What 
about the hours of operation, as I talked 
about before? What about citizenship? 
Affordability of these programs that are 
there, especially in those states that did 
not expand their Medicaid programs? 
Transportation, how people are going to 
get to and from the doctor? Sometimes 
it’s great to have an insurance card in your 
pocket, but if you don’t have the $20.00 to 
go round trip to your doctor that becomes a 
challenge for you to get that health care. 
DIRECT RELIEF: Will charitable healthcare 
remain a relevant model? 
NICOLE LAMOUREUX: Again, one of the most 
common misconceptions about how the 
U.S. will look after the full implementation 
of the ACA, is that there will no longer be a 
need for our clinics to continue to provide 
charity care as a member of the safety net. 
People are surprised to hear that according 
to the Congressional Budget Office – there 
may be as many as 29 million people, 
including documented, undocumented, 
and those who are eligible for Medicaid, 
but reside in states that are not going 
to expand this program, who are still 
without access to health insurance. So we 
feel at the national level in the upcoming 
months and years, doctors and hospitals, 
navigators, states, and our clinics, as well 
as other members of the safety net, will be 
addressing the needs of the underserved 
with respect to affordability and 
accessibility of primary, specialty, dental 
care, and medication access. There will 
continue to be a need for charity care in the 
United States after the full implementation 
of the Affordable Care Act. 
10 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS DirectRelief.org/USA
“ If you’re at 200% of the Federal Poverty Level, 
you’re still way down in what you’re bringing in 
to live. In the Bay Area, by the time you pay for 
your car, food, and housing, people don’t have 
an extra $115 dollars in their pocket to see a 
doctor. They just refuse to pay it. We see a lot of 
those patients.” 
—RICHARD GIBBS, PRESIDENT AND CO-FOUNDER, 
SAN FRANCISCO FREE CLINIC, CA 
“ I ANTICIPATE THAT WE WILL BE 
SEEING A LARGE INCREASE IN THE 
NUMBER OF FOLKS WHO WILL COME 
TO SEE US, WHICH PRESENTS US 
WITH CHALLENGES.” 
—DAN AHEARN, CEO, COMMUNITY HEALTH ALLIANCE, RENO, NV 
“THE UNDOCUMENTED WON’T QUALIFY 
FOR THE EXCHANGES, AND THEY WON’T 
EVEN QUALIFY FOR MEDICAID, SO I STILL 
THINK THAT OUR 25% UNINSURED RATE 
WILL STAY RELATIVELY CONSTANT, AT 
LEAST UNTIL SOME OF THE IMMIGRATION 
DEBATES ARE ULTIMATELY DECIDED 
AMONG CONGRESS.” 
— 
Sean Granahan, President/General Counsel, 
The Floating Hospital, Long Island City, NY 
“THE WAITING LIST IS SO LONG THAT WE CAN’T 
EVEN BEGIN TO HANDLE IT – IT WILL GET MORE 
MANAGEABLE. MAYBE WE’LL BE ABLE TO SEE 
MORE OF THE PEOPLE ON OUR WAITING LISTS 
THAT GOES ON FOR MONTHS AND MONTHS AND 
MONTHS, AND WE’LL BE ABLE TO GIVE THOSE 
SMALLER GROUPS OF PEOPLE THAT ARE LEFT 
WITHOUT ACCESS THE MUCH NEEDED HEALTH 
CARE THAT THEY NEED." 
—Florence Jameson, Founder and CEO, Volunteers in 
Medicine of Southern Nevada, Las Vegas, NV 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS // 11
 Sea Mar Community Health 
Center, Seattle, Washington 
THE PATIENTS 
People Cared for by the Safety Net 
PHOTO: DJORDJE ZLATANOVIC 
12 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
INCOME 
KNOWN INCOME LEVEL OF FQHC PATIENTS // 2013 
Total patients = 16.3 million 
TOTAL FQHC PATIENTS, KNOWN INCOME LEVELS // 2009-2013 
For the last five years the percent of individuals with incomes at or below 100% of the FPL 
seeking care at FQHCs has hardly varied (71.4-71.9%). While the percentage remained fairly 
stable, this is actually an aggregate increase from 10.1 million to 11.7 million individuals. 
7.2% 
OVER 
200% 
OF FPL 
14.5% 
101-150% 
OF FPL 
6.4% 
151- 
200% 
OF FPL 
71.9% 
AT OR BELOW 100% OF 
FEDERAL POVERTY LEVEL (FPL) 
The following provides an overview of demographic 
information from 2013 for the almost 22 million people 
treated annually at the nation’s Federally Qualified Health Centers 
(FQHCs). 
 21.7 MILLION TOTAL PATIENTS SERVED 
 7.6 MILLION PATIENTS (34.9%) LACKED 
HEALTH INSURANCE 
 Of individuals for whom income level was 
known, the vast majority (71.9%) were living 
at 100% or below of the Federal Poverty Level 
(FPL) – in 2013, that amounted to $11,490 for 
an individual and $23,550 for a family of four. 
The following charts show demographic information on patients at 
FQHCs in 2013, and what has changed compared to previous years. 
TOTAL PATIENTS IN MILLIONS 
2009 2010 2011 2012 2013 
AT OR BELOW 
100% OF FPL 
101-150% 
OF FPL 
151-200% 
OF FPL 
OVER 200% 
OF FPL 
0 
5 
10 
15 
20 
71.4% 71.8% 71.8% 71.9% 71.9% 
“A SIGNIFICANT NUMBER OF PATIENTS THAT 
WE SERVE DON'T QUALIFY FOR MEDICARE 
OR MEDICAID AND DON'T QUALIFY FOR OUR 
COUNTY'S HEALTH PLAN, WHICH IS FOR 
THOSE WITH VERY LOW INCOMES. HAD 
MEDICAID BEEN EXTENDED UP TO A GIVEN 
INCOME LEVEL OUR ESTIMATE IS THAT A 
THIRD OF THE PATIENTS TRADITIONALLY 
SEEN BY OUR FREE CLINIC WOULD HAVE 
QUALIFIED FOR MEDICAID.” 
—Beth Houghton, Executive Director, 
St. Petersburg Free Clinic, St. Petersburg, FL 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 13
INSURANCE 
INSURANCE SOURCE OF FQHC PATIENTS // 2013 
Total patients = 21.7 million 
34.9% 
NONE/UNINSURED 
39.8% 
MEDICAID 
14.1% 
PRIVATE 
8.4% 
MEDICARE 
2.0% PUBLIC 
0 
5 
10 
150 
20 
25 
PATIENTS IN MILLIONS 
2009 2010 2011 2012 2013 
MEDICAID 
NONE/UNINSURED 
PRIVATE INSURANCE 
MEDICARE 
PUBLIC INSURANCE 
38.2% 
37.1% 
37.5% 
38.6% 
36.4% 
39.3% 
36.0% 
39.6% 
34.9% 
40.6% 
TOTAL PATIENTS, INSURANCE SOURCE // 2009-2013 
From 2012 to 2013 not only did the uninsured percentage of patients seen at FQHCs decrease, 
but the aggregate number did as well, from 7.59 million to 7.57 million.* 2013 also saw an 
increase in patients using Medicaid, a continuation of the change seen in 2010 when Medicaid 
patients first exceeded uninsured patients. 
* The only other insurance category that decreased in both percentage and number was Other Public Insurance (non- 
Medicaid or Medicare). 
“OUR GUESS IS THAT WE WILL SEE STRONGER INFLUX OF THE WORKING POOR. WE WILL ALSO 
SEE PROBABLY ONLY ABOUT A 10% DROP, HOWEVER, IN OUR UNINSURED MEMBERS, AND WE 
ESTIMATE PERHAPS ONLY A 10% DROP IN WHAT’S CALLED OUR SELF-PAY CATEGORY, WHICH ARE 
PEOPLE WHO DON’T HAVE A LOT OF MONEY AND JUST PAY A SMALL PERCENTAGE OF WHAT THE 
ACTUAL VISIT COSTS.” 
—Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY 
14 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
"THERE’S A SIGNIFICANT PORTION 
OF OUR POPULATION THAT 
PROBABLY HAS NOT EVER 
BEEN INSURED IN 
THEIR ADULT LIFE." 
—RHONDA STUART, ENABLING SERVICES MANAGER, 
NORTHERN HEALTH CENTERS, LAKEWOOD, WI 
THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 15 
 Venice Family Clinic, Venice, California 
PHOTO: MARGARET MOLLOY 
DirectRelief.org/USA
NUMBER OF PATIENTS = 21.7 MILLION 
FEMALE = 12.7 MILLION PATIENTS MALE = 9.0 MILLION PATIENTS 
AGE OF PATIENTS 
FQHC PATIENTS NATIONAL POPULATION 2013 
65.2% 34.8% 
16.3% 
83.7% 
1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 
85+ 
80-84 
75-79 
70-74 
65-69 
60-64 
55-59 
50-54 
45-49 
40-44 
35-39 
30-34 
25-29 
20-24 
15-19 
10-14 
5-9 
0-4 
A 2013 SNAPSHOT OF GENDER, RACE, AND AGE/GENDER OF FQHC PATIENTS // 2013 
ETHNICITY AT FQHCs 
 Those aged 60-74 years were the fastest growing 
group as a proportion of the whole. This is a 
continued age increase from 2010 when the fastest 
growing group was those aged 50-64 years. 
 By gender, the five most common ages of patients 
seen at FQHCS were: 
Males 0-9 yrs (2,142,889) 
Females 20-29 yrs (2,128,691) 
Females 0-9 yrs (2,057,539) 
Females 30-39 yrs (1,887,387) 
Females 10-19 yrs (1,775,540) 
 The percentage of individuals identifying as White 
increased every year from 2008, 60.2% to 66.0% 
RACE OF FQHC PATIENTS // 2013 ETHNICITY OF FQHC PATIENTS // 2013 
23.8% 
BLACK 
66.0% 
WHITE 
3.9% 
MORE THAN ONE RACE 
3.6% 
ASIAN 
1.4% 
AMERICAN 
INDIAN/ 
ALASKA 
NATIVE 
1.3% 
HAWAIIAN/ 
PACIFIC 
ISLANDER 
NUMBER OF PATIENTS = 21.7 MILLION 
FEMALE = 12.7 MILLION PATIENTS MALE = 9.0 MILLION PATIENTS 
AGE OF PATIENTS 
FQHC PATIENTS NATIONAL POPULATION 2013 
NOT HISPANIC/LATINO 
HISPANIC/LATINO 
65.2% 34.8% 
16.3% 
83.7% 
1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 
85+ 
80-84 
75-79 
70-74 
65-69 
60-64 
55-59 
50-54 
45-49 
40-44 
35-39 
30-34 
25-29 
20-24 
15-19 
10-14 
5-9 
0-4 
16 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
“WE BELIEVE IT'S FAVORABLE BECAUSE, WE ARE 
ANTICIPATING ABOUT 3,000 OF OUR EXISTING 
PATIENTS WOULD BE ELIGIBLE FOR MEDICAID, 
FOR UP TO 133% OF THE FEDERAL POVERTY 
LEVEL. SO WITH THAT, WE ARE EXPECTING ABOUT 
3,000, AT LEAST, OF OUR EXISTING PATIENTS 
WHO WILL GO FROM HAVING ZERO INSURANCE TO 
HAVING AN AFFORDABLE OPTION.” 
—Shondra Williams, CEO, Jefferson Community 
Health Care Centers, Marrero, LA 
“MOST OF THE PEOPLE WHO ARE NEWLY 
ELIGIBLE, WHICH WE ANTICIPATE WILL BE 
125,000 SOUTHERN NEVADANS, IT'S NOT 
GOING TO HAPPEN LIKE THEY REGISTERED 
OVERNIGHT. THEY'RE GOING TO SHIFT 
SLOWLY IN THE NEXT YEAR OR TWO AS WE 
SHOW THEM THAT THEY'RE ELIGIBLE.” 
“Not everybody’s eligible, so it’s not going to 
completely eliminate the uninsured, so we still 
play a role. We’re better at dealing with some 
of these populations who have different needs. 
Certainly we have a lot of experience dealing with 
patients who don’t speak English, the chronically 
mentally ill, people with substance abuse issues, 
homeless people.” 
—TOM TOCHER, CHIEF CLINICAL OFFICER, COMMUNITY 
HEALTH CENTER OF SNOHOMISH COUNTY, EVERETT, WA 
"DOCTORS ARE SLOWLY NOT TAKING 
MEDICARE AND MEDICAID PATIENTS AND 
I DON'T KNOW WHAT WE'RE GOING TO 
DO BECAUSE THEY'RE GOING TO HAVE 
INSURANCE, OR MEDICARE, MEDICAID, AND AS 
THEY GET IT, THEY'RE NOT GOING TO BE ABLE 
TO UTILIZE IT BECAUSE I DON'T SEE A LOT OF 
NEW DOCTORS COMING ON." 
—JUDY JONES, EXECUTIVE DIRECTOR, BETHEL FREE HEALTH 
CLINIC INC., BILOXI, MS 
—FLORENCE JAMESON, FOUNDER AND CEO, VOLUNTEERS IN 
MEDICINE OF SOUTHERN NEVADA, LAS VEGAS, NV 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 17
THE CONDITIONS 
A Look at the Quality of Care in 
the Nonprofit Safety Net 
PHOTO: MARGARET MOLLOY 
 Clínica Monseñor Oscar A. Romero, 
Los Angeles, California 
18 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
2.4% 
ASTHMA 
11.1% 
HYPERTENSION 
22.8% SELECTED CHRONIC DISEASES 
7.5% 
DIABETES 
1.9% 
HEART DISEASE 
77.2% 
ALL OTHER PRIMARY DIAGNOSES 
• CHILDHOOD CONDITIONS 
• COMMUNICABLE DISEASES 
• DENTAL SERVICES 
• DIAGNOSTIC TESTS 
• MENTAL HEALTH & SUBSTANCE ABUSE CONDITIONS 
• NONCOMMUNICABLE DISEASES 
• PREVENTIVE SERVICES 
• SCREENINGS 
• OTHER SELECTED DIAGNOSES 
[ ] 
In 2011 the Health Resources and Services Administration changed the way in which diagnoses at Federally 
Qualified Health Centers were tracked to include all diagnoses at a visit, regardless of primacy. Previously only 
the primary diagnosis was used to estimate percent of patients with a condition or for tracking number of visits. The 
change, however, took into account that primary diagnosis alone likely underestimates the morbidity and burden 
of certain conditions for the patients and for the health centers. This hypothesis is carried out when comparing the 
data on total visits by diagnosis from 2011, for which the data showed 12.3% of visits were related to hypertension, 
diabetes, heart disease and asthma, and 2013, for which the new calculation gives 22.8% for the same four conditions. 
The new data collection parameters already show a greater number of patients than previously estimated for all 
tracked diagnoses, giving a more accurate portrayal of the burden on FQHCs for service provision. Particularly with 
chronic conditions, which account for a large percentage of total services provided, there is an even greater stress 
placed on clinics due to these conditions requiring services over a longer period of time. It is thus up to FQHCs to 
provide high quality care to a growing population of patients with increasing needs. 
22% OF ALL FQHC VISITS ARE RELATED TO 
SELECTED CHRONIC DISEASES // 2013 
“WE’RE EXCITED BECAUSE 
OUR PATIENTS WHO HAVE 
BEEN STRUGGLING WITHOUT 
INSURANCE FOR SO LONG, 
THIS IS AN OPPORTUNITY 
FOR THEM TO GET CARE AND 
TAKE CARE OF SOME OF THE 
THINGS THEY’VE PROBABLY 
BEEN PUTTING OFF.“ 
—Tom Tocher, Chief Clinical Officer, 
Community Health Center of Snohomish 
County, Everett, WA 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 19
QUALITY OF CARE DATA DIFFERENCE BETWEEN FQHC AND STATE HYPERTENSION RATES 
Safety-net health facilities, such as the Federally Qualified Health Centers, 
play a critical role in providing care for at least 1 in 13 Americans. As part 
of a health network caring for under- and uninsured working class poor that 
do not otherwise have access to health care it is important that not only do 
the services exist, but that they are of the highest standards. Indeed, a 2011 
study conducted by Randall Stafford, MD, PhD of Stanford University found that 
despite treating significantly more “medically and socially complex patients” 
than those seen by private providers, community health centers actually provide 
“better care than do private practices.” 
From 2010-2013 FQHCs saw the percentage of adults aged 18 and older 
with a hypertension diagnosis increase by 11.0%. In fact, hypertension as 
a primary or related diagnosis accounted for more visits in 2013 than any 
other condition, a total of 9,472,375. While the rate of FQHC patients with 
hypertension is increasing, the patient population at these safety-net facilities 
tend to actually have a lower rate than for the state population. 
Despite the increasing burden of hypertension, FQHCs have shown to 
provide the utmost in quality of care for patients. Stafford’s study identified 
blood pressure screening as one of six measures that FQHCs and FQHC Look- 
Alikes performed better on than private primary care practices. As well, almost 
all state FQHC populations have met the United States’ Healthy People 2020 
Target of 61.2% of adults with a hypertension diagnosis considered controlled. 
Fiftteen states have not yet met the Target, but even the state with the lowest 
percentage of controlled hypertension, Arkansas, is only 5.3 percentage points 
away, with five years remaining. 
HIGHEST AND LOWEST RATES OF CONTROLLED BLOOD 
PRESSURE IN THE FQHC POPULATION // 2013 
NEW HAMPSHIRE 
VERMONT 82.90% 
82.90% 
80.60% 
68.90% 
59.90% 
56.10% 
46.70% 
NORTH DAKOTA 
USA 
HAWAII 
DELAWARE 
WYOMING 
0 20 40 60 80 100 
72.50% 
70.60% 
69.90% 
63.60% 
58.70% 
56.60% 
55.90% 
VERMONT 
MAINE 
PENNSYLVANIA 
USA 
MISSOURI 
ALABAMA 
ARKANSAS 
0 10 20 30 40 50 60 70 80 
CONTROLLED BLOOD PRESSURE AT FQHCs // 2013 
States colored in blue have a lower rate of diagnosed hypertension at FQHCs than the rate for that 
respective state. States in red scale have a greater rate of diagnosed hypertension at FQHCs. 
Healthy People 2020 lists controlled hypertension as a Leading Health Indicator. The Target is 
61.2% of adults with a hypertension diagnosis considered controlled. Thirty-five states have met the 
Target within the FQHC population. 
20 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
"I feel like IT'S DEFINITELY GOING 
TO CHANGE THE OVERALL HEALTH 
OF AMERICA. For countries that have 
universal health coverage, patients don't wait 
to seek care. There's a reduction of chronic 
disease because there's prevention and early 
detection. It's going to be the same for America 
down the road." 
—SHANE CHEN, CHIEF OPERATIONS OFFICER, 
ASIAN AMERICAN HEALTH COALITION CLINIC, HOUSTON, TX 
 Venice Family Clinic, Venice, California 
PHOTO: MARGARET MOLLOY 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 21
DIFFERENCE BETWEEN FQHC AND STATE DIABETES RATES 
HIGHEST AND LOWEST RATES OF CONTROLLED 
DIABETES IN THE FQHC POPULATION // 2013 
NEW HAMPSHIRE 
VERMONT 82.90% 
82.90% 
80.60% 
68.90% 
59.90% 
56.10% 
46.70% 
NORTH DAKOTA 
USA 
HAWAII 
DELAWARE 
WYOMING 
0 20 40 60 80 100 
CONTROLLED DIABETES AT FQHCs // 2013 
A condition that has a similar weight on safety net resources is diabetes. 
Of note is that diabetes is over represented amongst FQHC patients compared 
to the rest of the US population. The rate of diagnosed diabetes among adults 
aged 18 and older is higher in the FQHC population in all but one state. As 
many FQHCs continue to see an increase in the proportion of patients with 
controlled diabetes, they are also thus faced with a greater demand for services 
and medication. No state has yet met the Healthy People 2020 Target of 83.9% 
of adults with a diabetes diagnosis considered controlled. The over burden of 
diabetes exemplifies the need for support and resources to enable safety-net 
facilities to provide and expand quality care for all their patients. 
These quality of care measures for chronic diseases are important as if 
these intermediate outcomes are improved, then later poor health outcomes 
will be far less likely. Direct Relief USA works with more than 1,200 clinic 
partners across the country, more than half of which are Federally Qualified 
Health Centers like the ones studied. The report from Stanford and the 
collected FQHC data confirm that the patients Direct Relief’s clinic partners 
serve can access quality care from what many acknowledge is an already-strained 
network caring for a disproportionate share of socially vulnerable and 
chronically ill patients. 
“These are centers where physicians are not as profit-driven and many have 
incentives more in line with providing quality care,” said Dr. Stafford. 
States colored in blue have a lower rate of physician diagnosed diabetes at FQHCs than the rate for 
that respective state. States in red scale have a greater rate of diagnosed diabetes at FQHCs. 
Healthy People 2020 lists controlled diabetes (Hb A1c <9%) as a Leading Health Indicator. The 
Target is 83.9% of adults with a diabetes diagnosis considered controlled. No state has yet met the 
Target within the FQHC population. 
22 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
" I THINK THE ACA WILL 
HELP PEOPLE HAVE ACCESS 
TO SPECIALISTS THAT 
PREVIOUSLY THEY DID NOT 
HAVE ACCESS TO." 
—BARB TYLENDA, EXECUTIVE DIRECTOR, 
HEALTH CARE NETWORK, RACINE, WI 
"THERE ARE THOSE WHO THINK THAT 
THERE WON'T BE A NEED FOR FREE CLINICS. 
I THINK NOTHING COULD BE FARTHER FROM 
THE TRUTH. I'M BANKING ON THE FACT 
THAT WE'RE GOING BE NEEDED, AND WE'RE 
GOING HAVE A LOT OF PEOPLE WHO STILL 
NEED ASSISTANCE AND WE'RE GOING BE 
ABLE TO CARE FOR THEM." 
—Jim Harris, CEO, Health Access Incorporated, Clarksburg, WV 
“WILL IT IMPROVE PATIENTS OVERNIGHT? 
NO. I THINK IT’S GOING TO TAKE SEVERAL 
YEARS TILL WE CAN REALLY SAY HAVING 
ACCESS INCREASES OR DOES NOT 
INCREASE THE HEALTH STATUS.” 
—Dan Ahearn, CEO, Community Health Alliance, Reno, NV 
"IT’S GREAT TO HAVE INSURANCE. DON’T GET ME 
WRONG. BUT YOU STILL HAVE TO HAVE ACCESS 
TO CARE. AND FOR OUR SICK PATIENTS, THE ONES 
THAT ARE UNINSURED, YOU HAVE TO HELP THEM 
UNDERSTAND HOW IMPORTANT IT IS TO TAKE CARE OF 
YOURSELF WHEN YOU HAVE CHRONIC DISEASES." 
—ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, WILLIAM F. RYAN 
COMMUNITY HEALTH CENTER, NEW YORK, NY 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 23
THE COMMUNITIES 
Medicaid and the Nonprofit Safety Net 
PHOTO: GREG DAVIS 
 Sea Mar Community Health Center, 
Seattle, Washington 
24 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
A DEEPER DIVE INTO THE ROLE OF THE SAFETY NET 
DURING MEDICAID EXPANSION – AND IN STATES 
WITHOUT MEDICAID EXPANSION 
As of September 2014 the preeminent issue for understanding 
the impact of the ACA upon uninsured people across the country 
remains the status of their state relative to the Medicaid expansion 
portion of the law. According to a study published in Health Affairs1 
along with related studies published by RAND2 and the Kaiser Family 
Foundation3, there are likely an estimated 8 million individuals living 
in the 25 states which are not expanding Medicaid who would be newly 
insured this year had their states opted in to the Medicaid expansion 
provisions of the ACA. Almost all of these individuals will remain 
uninsured, given that their incomes will likely remain too low to qualify 
for the health insurance exchange subsidies, yet not low enough to fall 
within prior Medicaid qualifications. Subsidy amounts were set at a 
minimum of 138 percent of the Federal Poverty Level (FPL) for a family of 
three, under the assumption that Medicaid expansion would take care of 
coverage for those households and individuals between 100 percent and 
138 percent of FPL. 
Among those nearly 8 million uninsured individuals exist hundreds 
of thousands of cases of depression, diabetes, and other chronic 
illnesses which will likely require some form of charitable mechanism 
to address. The most incisive study to date on the possible impact of 
the uneven Medicaid expansion landscape on the health of people 
without insurance was published by JAMA in April 20144. According to 
the authors’ interpretation of health data collected from a national pool 
of roughly 19,000 persons living under the 138% FPL threshold, chronic 
conditions such as hypertension, cancer, stroke, and respiratory diseases 
were significantly more prevalent amongst those living in non-expansion 
states. In other words, poor residents of non-expansion states will 
not only be unlikely to receive additional assistance from the ACA with 
improved access to healthcare payments, but are also already in poorer 
CURRENT STATUS OF MEDICAID EXPANSION DECISION 
Implementing Expansion in 2014 Not Moving Forward at this Time 
1 (http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and- 
financial-impacts/) 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 25
LAS VEGAS, NV 
NEW ORLEANS, LA 
health than their counterparts in Medicaid expansion states. Granted, health insurance 
in itself does not guarantee access to quality healthcare. Yet the best evidence available 
indicates that where you live in the future may play an even greater role in the health 
outcomes than it has so far. 
Local, just as much as national, landscapes of care are shaped by the conditions 
of place. Cities like Las Vegas, NV and New Orleans, LA face very similar challenges 
in the post-ACA world. The populations of these cities are of similar population size 
and income distributions. Both have dealt with significant challenges over the past 
several years: Las Vegas through the crisis in the housing market and the pressures of 
economic recession, New Orleans with the aftershocks of Hurricane Katrina and their 
own recessionary trends since 2008. Mapping the census blocks of each city according to 
the ACA’s new Medicaid eligibility levels (138% FPL) in relation to the locations of safety 
net facilities reveals high densities of proximate neighborhoods with high likelihood of 
significant numbers of newly insured people. Yet, of course, these landscapes mean very 
different things in 2014 based upon differences in approach at the state level to the ACA. 
In Las Vegas, given that Nevada is participating in the Medicaid expansion, census blocks 
with median income levels of 138% FPL and below will be likely to put pressure on the 
safety net through increases in new Medicaid patients. In New Orleans, however, given 
Louisiana’s opposition to the Medicaid expansion, this very same landscape is one which 
indicates persistent uninsured levels and sizeable ongoing gaps in the ability to pay for 
healthcare services. In each case, safety net institutions face significant pressures, but 
the nature of those pressures differs markedly depending on where they occur and how 
their states have chosen to approach the implementation of the ACA. 
2 (http://www.rand.org/health/aca/medicaid_expansion.html) 
3 (http://kff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/) 
4 (https://archinte.jamanetwork.com/article.aspx?articleid=1857090) 
26 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
“WE KNOW A LITTLE OVER 90,000 PEOPLE IN OKLAHOMA 
COUNTY ARE UNINSURED AND HAVE A HOUSEHOLD 
INCOME AT 200 PERCENT FEDERAL POVERTY LEVEL. 
WE WERE REALLY HOPEFUL THAT, IF EVEN A THIRD OF 
THEM WERE ABLE TO MOVE ONTO MEDICAID AND HAVE 
A PAYMENT SOURCE THAT IT WOULD MAKE A HUGE 
DIFFERENCE IN OUR WORKLOAD. THAT’S NOT HAPPENING… 
SO UNFORTUNATELY, WHEREAS WE THOUGHT THINGS 
MIGHT BE IMPROVING FOR OUR POPULATION IT’S NOT 
GOING TO IMPROVE VERY MUCH.” 
—PAM CROSS-CUPIT, EXECUTIVE DIRECTOR, HEALTH 
ALLIANCE FOR THE UNINSURED, OKLAHOMA CITY, OK 
" MY GUT FEELING IS THAT THERE STILL WILL BE A 
SIGNIFICANT NUMBER OF UNINSURED IN NEW YORK 
CITY BECAUSE WE HAVE SO MANY UNDOCUMENTED 
FOLKS LIVING IN NEW YORK CITY. WE’LL STILL BE 
SERVING THOSE PATIENTS, BUT THEY STILL WON’T HAVE 
INSURANCE, BUT THEY’LL STILL COME TO THE FQHCS." 
—ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, WILLIAM F. RYAN 
COMMUNITY HEALTH CENTER, NEW YORK, NY 
“NOT MANY PRIMARY CARE DOCTORS’ OFFICES ARE 
GOING TO BE ABLE TO TAKE IN A LARGE AMOUNT OF 
MEDICAID PATIENTS BECAUSE EVEN THOUGH SOME OF 
THE MEDICAID PATIENT’S PAYMENTS MAY GO UP TO 
MEDICARE LEVELS IT’S DIFFICULT TO KEEP THE LIGHTS 
ON AND THE DOORS OPEN WITH THAT.” 
—Dan Ahearn, CEO, Community Health Alliance, Reno, NV 
" The greatest challenge is with the hospital 
acute care centers. There are, in Louisiana 
specifically, and more importantly, in 
our parish, two major hospitals that are 
considering closing or being purchased by a 
new entity, and it’s because they're unsure of 
their financial feasibility in the climate where 
their disproportionate funds are going to be 
reduced or eliminated as a result of ACA." 
—Shondra Williams, CEO, Jefferson Community 
Health Care Centers, Marrero, LA 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 27
Community health centers are experiencing in 2014 an overall 
increase nationwide in people seeking care at their facilities, but 
a decrease in people who are uninsured. This finding accords with a 
number of other recent indicators showing that the ACA does appear 
to be reducing uninsured rates nationally. However, Direct Relief’s 
poll also shows that the impact of the ACA is highly variable based 
upon geography. Respondents in states which are not expanding the 
Medicaid program overwhelmingly reported that their uninsured 
rates have actually been increasing, whereas the opposite was true 
in states which have undertaken Medicaid expansion. Respondents 
from states that have adopted expanded Medicaid eligibility 
authorized under the Affordable Care Act also indicated that they 
hold a substantially more favorable view of the law’s impact than 
those in non-expansion states. 
These findings come from a poll of nearly 100 community health 
centers conducted by Direct Relief in August 2014 at the annual 
conference of the National Association of Community Health Centers. 
Survey respondents collectively serve more than 1.5 million people 
and operate clinical sites in 27 U.S. states. 
FLASH POLL: 
COMMUNITY HEALTH & 
MEDICAID EXPANSION 
2014 COMMUNITY HEALTH 
INSITITUTE & EXPO 
MEDICAID EXPANSION STATE 48.0% 
MEDICAID 
EXPANSION STATE 
NON-EXPANSION STATES IN DEBATE 
NON-EXPANSION STATE 46.4% 
IN DEBATE 5.4% 
0 
2 
4 
6 
8 
10 
12 
IN MILLIONS 
1,120,000 
353,000 
37,000 
MEDICAID EXPANSION STATE 48.0% 
MEDICAID 
EXPANSION STATE 
NON-EXPANSION STATES IN DEBATE 
NON-EXPANSION STATE 46.4% 
IN DEBATE 5.4% 
0 
2 
4 
6 
8 
10 
12 
IN MILLIONS 
1,120,000 
353,000 
37,000 
RESPONDENT LOCATION 
PATIENTS REPRESENTED BY RESPONDENTS 
28 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
81.5% 
3.7% 
14.8% 
76.9% 
64.0% 
16.0% 
20.0% 
58.3% 
16.7% 
25.0% 
19.2% 
3.8% 
19.2% 
96.3% 
0.0% 
3.7% 
50.0% 
30.8% 
INCREASE 
DECREASE 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
POSITIVELY 
NEGATIVELY 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
POSITIVELY 
NEGATIVELY 
NO CHANGE 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
0 20 40 60 80 100 
81.5% 
3.7% 
14.8% 
76.9% 
64.0% 
16.0% 
20.0% 
58.3% 
16.7% 
25.0% 
19.2% 
3.8% 
19.2% 
96.3% 
0.0% 
3.7% 
50.0% 
30.8% 
INCREASE 
DECREASE 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
POSITIVELY 
NEGATIVELY 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
INCREASE 
DECREASE 
NO CHANGE 
POSITIVELY 
NEGATIVELY 
NO CHANGE 
IN 2014 SO FAR, HAS 
YOUR FACILITY SEEN 
A CHANGE IN THE 
TOTAL NUMBER OF 
PATIENTS? 
IN 2014 SO FAR, HAS 
YOUR FACILITY SEEN 
A CHANGE IN THE 
TOTAL NUMBER OF 
PATIENTS WITHOUT 
INSURANCE? 
HOW DO YOU THINK 
THE AFFORDABLE 
CARE ACT, OVERALL, 
HAS AFFECTED YOUR 
FACILITY? 
STATES EXPANDING MEDICAID STATES NOT EXPANDING MEDICAID 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 29
BACKGROUND 
Direct Relief USA and the Safety Net 
PHOTO: MARGARET MALLOY 
 Clínica Monseñor Oscar A. Romero, 
Los Angeles, California 
30 // THE STATE OF THE SAFETY NET 2014 // BACKGROUND DirectRelief.org/USA
Since 1948, Direct Relief has provided humanitarian assistance to improve the 
health and quality of life of people affected by poverty and disasters throughout 
the world by providing essential material resources—medicine, medical supplies, 
and basic equipment. Direct Relief is the nation’s leading nonprofit provider of 
donated medicines to community clinics, free clinics, and community health centers 
for low-income patients without health insurance. It operates the largest charitable 
medicines program of its kind, and is the only nonprofit that is certified by the 
National Association of Boards of Pharmacy to distribute prescription medicine in all 
50 states. Since 2004, Direct Relief has delivered more than $440 million (wholesale) 
in medical resources to more than 1,200 nonprofit clinic and health centers. 
Direct Relief is recognized for its fiscal strength, accountability and efficiency, 
and consistently achieves top rankings from Forbes, Charity Navigator (including 
“Top Charity” and “4-Stars”), the Better Business Bureau, and Consumers Digest. In 
2011, Forbes rated Direct Relief “100% efficient” and “[Among the] 20 most efficient 
large U.S. charities.” 
BASED ON DAILY INTERACTION 
WITH PARTNERS, DIRECT RELIEF 
REQUESTS NEEDED MEDICAL 
PRODUCTS FROM 150 HEALTHCARE 
COMPANIES. 
DIRECT RELIEF NOTIFIES CLINIC AND HEALTH CENTER 
PARTNERS OF AVAILABLE PRODUCTS THROUGH THE 
DIRECT RELIEF NETWORK. CLINICS CAN PLACE A 
REQUEST FOR DONATED PRODUCTS FOR THEIR LOW-INCOME 
PATIENTS WITHOUT HEALTH INSURANCE. 
PRODUCTS ARE DELIVERED TO THE 
PARTNERS COURTESY OF FEDEX, 
FREE OF CHARGE, TO BE GIVEN TO 
PATIENTS. 
DIRECT RELIEF PHARMACISTS REVIEW ALL 
PRODUCT REQUESTS AND ADJUST AS NECESSARY 
BASED ON THE AVAILABILITY OF REQUESTED 
PRODUCTS AND THE INFORMATION CLINICS 
PROVIDE ABOUT THEIR HEALTH FACILITIES. 
Rx 
DIRECT RELIEF’S CLINIC AND HEALTH CENTER PARTNER NETWORK 
11 million patients 
55.4% 
FQHC/LOOK-ALIKE 
608 
FQHC/LOOK-ALIKE 
34.3% 
FREE CLINIC 
9.7% 
COMMUNITY 
CLINIC 
99 
COMMUNITY CLINIC 
X% 
PUBLIC HEALTH 
DEPARTMENT 
4 
PUBLIC HEALTH 
DEPARTMENT 
X% 
OTHER 
53 
SOCIAL SERVICES 
398 
FREE CLINIC 
9 
OTHER 
HOW IT WORKS 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // BACKGROUND // 31
METHODOLOGIES // DATA SOURCES 
HEALTH RESOURCES AND SERVICES ADMINISTRATION 
Uniform Data System 
The information presented here applies to those entities from which the U.S. Department of Health and Human Services’ Health 
Resources and Services Administration (HRSA) collects data through the Uniform Data System (UDS). These are grantees of the 
following HRSA primary care programs: Community Health Centers, Health Care for the Homeless, and Public Housing Primary 
Care providers. Grantees can be found in all 50 states, the District of Columbia, and U.S. territories. The reported data should not be 
extrapolated to any other population as it is representative only of those individuals who utilize services of FQHC grantees. Please note 
that rates of diagnoses, insurance levels, demographics, etc. are descriptive measurements to provide context and are not intended for 
the sake of population-level analysis or comparison with institutions that are not nonprofit safety-net health centers and clinics. For 
example, a particular health center might show that a high percentage of its patient population consists of homeless individuals. This 
does not necessarily mean that the area in which it operates has an exceptionally high rate of homelessness. Rather, the health center 
may have specific programs and outreach aimed at bringing health care to homeless individuals. Such a program therefore would skew 
the facility’s patient population numbers not only away from the norm of its service area, but also from levels seen at FQHCs without 
such programs. Likewise, disease diagnosis rates recorded at these institutions should not be mistaken for disease prevalence rates 
among the area’s general population. It should also be noted, however, that all FQHCs are located by law in areas that are deemed by 
the federal government to be medically underserved. 
COMMUNITY HEALTH INSTITUTE AND EXPO FLASH POLL – During the 2014 Community Health Institute and Expo hosted by the 
National Association of Community Health Centers, Direct Relief surveyed attendees regarding their perceptions related to health 
centers, their patient population, and the Affordable Care Act. The survey was a total of six questions and each respondent represented 
an individual from a health center. Fifty-six responses were garnered from this population from August 23-24, 2014. 
© Direct Relief 2014 
All rights reserved. Requests for 
permission to reproduce should be 
addressed to Direct Relief, 
27 South La Patera Lane, Santa Barbara, 
CA, 93117. Phone: (800) 676-1638; fax: 
(805) 681-4838; email: info@directrelief.org. 
Authors 
Andrew Schroeder, PhD, MPP; 
Damon Taugher; Thomas Tighe; 
Jennifer Lemberger, MPH 
Art Direction 
Andrew Fletcher 
Design 
Leslie Lewis Sigler, studio-sigler.com 
METHODOLOGIES 
32 // THE STATE OF THE SAFETY NET 2014 // METHODOLOGIES DirectRelief.org/USA
VOICES OF THE SAFETY NET 
Interviews took place with nonprofit safety-net clinic and health center staff, as well as national associations from 
August 2013 – March 2014. Quotes from the following interviews are included in this report: 
Dan Ahearn, CEO, Community Health Alliance, Reno, NV 
Jane Calhoun, VP Medical Affairs & Clinical Director, Delta Health Alliance, Stonesville, MS 
Shane Chen, Chief Operations Officer, Asian American Health Coalition Clinic, Houston, TX 
Pam Cross-Cupit, Executive Director, Health Alliance for the Uninsured, Oklahoma City, OK 
Alieta Eck, Founder, Zarepath Health Center, Somerset, NJ 
Richard Gibbs, President and Co-Founder, San Francisco Free Clinic, San Francisco, CA 
Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY 
Jim Harris, CEO, Health Access Incorporated, Clarksburg, WV 
Beth Houghton, Executive Director, St. Petersburg Free Clinic, St. Petersburg, FL 
Florence Jameson, Founder and CEO, Volunteers in Medicine of Southern Nevada, Las Vegas, NV 
Judy Jones, Executive Director, Bethel Free Health Clinic Inc., Biloxi, MS 
Rhonda Stuart, Enabling Services Manager, Northern Health Centers, Lakewood, WI 
Ana Taras, Chief of Strategic Initiatives, William F. Ryan Community Health Center, New York, NY 
Tom Tocher, Chief Clinical Officer, Community Health Center of Snohomish County, Everett, WA 
Barb Tylenda, Executive Director, Health Care Network, Racine, WI 
Shondra Williams, CEO, Jefferson Community Health Care Centers, Marrero, LA 
Nicole Lamoureux, Executive Director National Association of Free and Charitable Clinics, Alexandria, VA 
“HEALTH INSURANCE IS A CARD ISSUED BY THE STATE AND DOES NOT GUARANTEE ACCESS TO MEDICAL CARE. IF THERE ARE NO DOCTORS TO 
TAKE IT…CHARITY CARE WILL REMAIN A VERY VIABLE OPTION, AND THE THING ABOUT HEALTH INSURANCE—SOMEHOW WE’VE BOUGHT THE 
LIE THAT EVERYBODY NEEDS HEALTH INSURANCE TO GET MEDICAL CARE, WHEN SOMEBODY WITHOUT ACCESS DOES NOT NEED INSURANCE. 
WHAT THEY NEED IS A PLACE TO GO WHEN THEY FIND THEMSELVES SICK AND IN NEED OF MEDICAL CARE, AND WITHOUT ANY FUNDS.” 
— Alieta Eck, Founder, Zarepath Health Center, Somerset, NJ 
DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // METHODOLOGIES // 33
> LEARN MORE 
DirectRelief.org/USA 
Learn more about Direct Relief’s work 
throughout the United States and see an 
interactive map of the medical support 
Direct Relief provides to over 1,200 
health centers and clinics. 
> MAKE A DONATION 
DirectRelief.org/donate 
Direct Relief is a private, charitable 
organization that does not receive 
government funding and depends on the 
generous support of private businesses, 
individuals, and grantmaking organizations 
to improve access to essential health 
services in the United States and 
worldwide. 
> FOR PRESS/MEDIA INQUIRIES 
Contact Kerri Murray at (800) 676-1638, 
or kmurray@directrelief.org. 
LEARN MORE ABOUT THE SAFETY NET // 
DIRECTRELIEF.ORG/USA 
> DIRECT RELIEF 
27 South La Patera Lane 
Santa Barbara, CA 93117 USA 
(800) 676-1638 
PHOTO: ANDREW FLETCHER 
34 // THE STATE OF THE SAFETY NET 2014 // LEARN MORE DirectRelief.org/USA

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State of the safety net 2014

  • 1. THE STATE OF THE SAFETY NET 2014 Healthcare Reform and the Safety Net PHOTO: MARGARET MOLLOY  Clínica Monseñor Oscar A. Romero, Los Angeles, California
  • 2. AT LEAST 10,000 HEALTH FACILITIES 50 STATES 24 MILLION PATIENTS  35% LACK INSURANCE 72% ARE BELOW POVERTY LEVEL 4 // INTRODUCTION 6 // TERMINOLOGY 8 // THE PROVIDERS 12 // THE PATIENTS 18 // THE CONDITIONS 24 // THE COMMUNITIES 30 // BACKGROUND 32 // METHODOLOGIES WILLIAM VAZQUEZ FOR ABBOTT FUND CONTENTS 2 // THE STATE OF THE SAFETY NET 2014 // CONTENTS DirectRelief.org/USA
  • 3. PHOTO: MARGARET MOLLOY "We’re excited because we want people to have access. That’s what our mission is; health care is a right not a privilege, but we just need to make sure that we’re financially healthy as well." —ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, WILLIAM F. RYAN COMMUNITY HEALTH CENTER, NEW YORK, NY  Clínica Monseñor Oscar A. Romero, Los Angeles, California DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // CONTENTS // 3
  • 4. PHOTO: CHASS The Affordable Care Act (ACA) is a sea change in the U.S. healthcare system. In the context of that change, the critical role of nonprofit safety-net healthcare providers warrants particular attention. Providing care to more than 24 million people, these health centers and clinics are on the front lines of treating those who are most in need, without insurance, and living in poverty. This report, as in past reports, aims to provide a current overview of these providers. In this edition we have also added a snapshot of their perspectives on the ACA. Interviews were conducted over the past year with an array of providers—large and small facilities, free clinics and Federally Qualified Health Centers, providers in rural and urban environments, in states that have expanded Medicaid and states that have opted out. The goal was to understand the pending impact of one of the most sweeping laws our nation has seen on the providers that are, in many ways, most important to reaching disadvantaged communities. Perhaps, not surprisingly, there is a wide range of views and feelings among safety net health providers. Four common threads recurred. TAKEAWAYS 1. At the highest level, all providers, regardless of location, size, or facility type, underscored that for the foreseeable future the need for charitable health care will remain. The need for charitable care is perhaps most obvious in the states that have chosen not to expand Medicaid, which will under any immediate scenario continue to have higher levels of people who are uninsured than in the expansion states. Beyond this very obvious need there will continue to be gaps in coverage for immigrants (undocumented and otherwise) and those who will otherwise fall through the cracks. 2. As safety net providers have long known, having insurance is not the same as having access to a high-quality health care provider. Great unease exists throughout the safety net about demand for services among the newly insured, dramatically outpacing the supply of health facilities and health professionals. INTRODUCTION  Community Health and Social Services, Detroit, Michigan 4 // THE STATE OF THE SAFETY NET 2014 // INTRODUCTION DirectRelief.org/USA
  • 5. 1. At the highest level, all providers, regardless of location, size, or facility type, underscored that for the foreseeable future the need for charitable health care will remain. 2. As safety net providers have long known, having insurance is not the same as having access to a high-quality health care provider. 3. Geography matters — one cannot talk about the Affordable Care Act without taking about differences of place. 4. Safety net providers consistently pointed out that we are only at the very beginning stages of the momentous changes yet to come. 3. Geography matters – one cannot talk about the Affordable Care Act without taking about differences of place. Vast unevenness exists in the law’s application, most obviously again in the split between Medicaid expansion and non-expansion states. But that geographic unevenness is amplified by unevenness in the functionality of the new insurance exchanges (federal and state), in the public health and economic conditions of different areas of the country, and even in the differential risk of natural disasters in places where the law’s outcomes are as yet unknown. 4. Safety net providers consistently pointed out that we are only at the very beginning stages of the momentous changes yet to come. Change of this scale cannot happen overnight. The shifting landscape of insurance coverage and health providers that treat low income patients is creating a more complex safety net; the provision of charitable care must rise to meet the challenge of that additional complexity. As people receive coverage they in some cases had never had before in their lives, it is a new experience for them and will take time to adjust. While the ACA is a national law, the practice of US health care, particularly for the most vulnerable parts of our population, is changing on a community by community basis. As the report details, the perspectives of these providers on the implications and outcomes of the ACA have much to do with where they exist, what type of facility they are, and what sort of population they serve. The environments range dramatically – from states that have moved forward with Medicaid expansion compared with states that have not, some of which already have significantly greater disease burdens and risks than others. Facilities range widely from larger and more established health centers with staff that have extensive experience assisting with insurance enrollment, as compared to smaller, volunteer run free clinics with minimally comparable background. Still, though their environments may differ, their purpose does not: ensuring that everyone, regardless of their ability to pay or their personal background, have access to safe, high-quality healthcare. Direct Relief is the sole nonprofit licensed to distribute prescription medicines in all 50 states and runs the largest U.S. charitable medicines program through a network of more than 1,200 of these providers in all 50 states. A unique perspective is afforded from our close, daily interaction to understand these providers' circumstances, needs, interests, and concerns and, in turn, mobilize and deliver charitable resources efficiently. One thing that our interactions with safety net providers has consistently shown us is that the most informed and thoughtful views are not always delivered in the loudest voice or even heard at all over the din of vigorous debate. These leaders' voices, experienced and reflective of the breadth of circumstances that exist on the frontlines of the healthcare safety net, describe the strong influence of place and the differences in circumstances that exist. For the millions of people that depend on America's nonprofit healthcare safety net, we hope these voices will be heard much more in the years to come. “ TRYING TO PROVIDE FOR UNINSURED PATIENTS—WE’RE GOING TO KEEP DOING THAT UNTIL WE KNOW THERE IS AN ANSWER. WE ARE GOING TO KEEP DOING WHAT WE’RE DOING AND MAKING A WAY TO PROVIDE GOOD QUALITY CARE FOR UNINSURED PATIENTS.” —Jane Calhoun, VP Medical Affairs & Clinical Director, Delta Health Alliance, Stonesville, MS 4 TAKEAWAYS DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // INTRODUCTION // 5
  • 6. > Affordable Care Act (courtesy of the Kaiser Family Foundation) – Requires most U.S. citizens and legal residents to have health insurance. Creates state-based American Health Benefit Exchanges through which individuals can purchase coverage, with premium and cost sharing credits available to individuals/families with income between 133-400% of the Federal Poverty Level and creates separate Exchanges through which small businesses can purchase coverage. Requires employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers. Impose new regulations on health plans in the Exchanges and in the individual and small group markets. Expands Medicaid to 133% of the Federal Poverty Level. > Direct Relief Partner – a community clinic, Federally Qualified Health Center, or free or charitable clinic that was vetted and approved to be part of the Direct Relief Partner Network. > Direct Relief Partner Network – the network of more than 1,200 community clinics, Federally Qualified Health Centers, and free or charitable clinics that Direct Relief currently supports with donations of free medicine and medical supplies. > Federal Poverty Level (FPL) – the set minimum amount of gross income that a family needs for food, clothing, transportation, shelter, and other necessities as determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. > Medicaid – a U.S. government program—financed by federal, state, and local funds— that provides health coverage for lower-income people, families and children, the elderly, and people with disabilities. TERMINOLOGY > Safety Net – the network of nonprofit provider agencies that deliver health services to vulnerable populations experiencing financial, cultural, linguistic, geographic, or other obstacles to accessing adequate health care. The nation’s healthcare safety net includes more than 10,000 clinical sites providing comprehensive, culturally-competent health services to more than 24 million people regardless of their ability to pay. TYPES OF SAFETY-NET FACILITIES > Community Clinic – a nonprofit provider agency that treats anyone regardless of ability to pay, but generally charges patients on a sliding fee scale. > Federally Qualified Health Center (FQHC) – public and private nonprofit healthcare providers located in medically underserved areas that treat anyone regardless of ability to pay, and meet certain federal criteria under the Health Center Consolidation Act (Section 330 of the Public Health Service Act). There are 1,202 FQHCs operating over 8,000 sites in 2013 that treated 21.7 million people across the United States, of whom 7.6 million lacked health insurance. > Free Clinic – a nonprofit, usually volunteer-based provider facility that treats anyone regardless of ability to pay, typically free of charge or with a nominal donation for services. An estimated 1,200 free clinic operate across the United States. > Look-Alike – an organization that meets the eligibility requirements of Section 330 of the Public Health Service Act, but does not receive federal grant funding. Look-Alikes receive many of the same benefits as FQHCs, including enhanced Medicare and Medicaid reimbursement, and eligibility to purchase prescription and non-prescription medications at a reduced rate. There were 100 Look-Alikes in 2013 that treated 1.0 million people across the United States, of whom 329,000 lacked health insurance. 6 // THE STATE OF THE SAFETY NET 2014 // TERMINOLOGY DirectRelief.org/USA
  • 7. "PLACES LIKE US THAT ARE SMALL, TOTALLY FREE, AND DON’T PARTICIPATE IN GOVERNMENT MONEY ARE GOING TO BE THE NEW SAFETY NET FOR PEOPLE FALLING THROUGH THE NET OF THE AFFORDABLE CARE ACT." —RICHARD GIBBS, PRESIDENT AND CO-FOUNDER, SAN FRANCISCO FREE CLINIC, SAN FRANCISCO, CA  Venice Family Clinic, Venice, California PHOTO: MARGARET MOLLOY DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // TERMINOLOGY // 7
  • 8.  Community Health and Social Services, Detroit, Michigan THE PROVIDERS Safety Net Voices and the Affordable Care Act PHOTO: CHASS 8 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS DirectRelief.org/USA
  • 9. An interview with Nicole Lamoureux, Executive Director, National Association of Free and Charitable Clinics DIRECT RELIEF: Can you provide some background into your association and free clinics? NICOLE LAMOUREUX: The National Association of Free and Charitable Clinics is the only national organization that is organized and developed to work with free clinics in the communities they serve. Our mission is to broaden access to affordable health care for the medically underserved by increasing public awareness, promoting volunteerism, and supporting and advocating for the nation’s Free and Charitable Clinics as we work together to build a healthy America, one patient at a time. Many people do not realize that there are approximately 1,200 free or charitable clinics throughout the nation, who, since the 1960s, have been filling in the gap for those who fall through the cracks in our current healthcare system. Our clinics believe in giving a hand up, not a hand out. We activate at the grass roots level, not at the government level. What sets us apart from our other counterparts in the safety net arena is that we receive little to no state or federal funding and we are not considered Federally Qualified Health Centers. Our clinics rely very heavily on the generosity of individual donors, foundations, and grants as funding sources, and we utilize a staff and volunteer model to provide health care to those in our communities who need it the most. DIRECT RELIEF: As the legislation has begun to roll out, how do you see the initial impact affecting free clinics? NICOLE LAMOUREUX: The first thing that I stress when I’m speaking to people is one of the most common misconceptions about how the United States will look after the full implementation of the ACA is that there will no longer be a need for free or charitable clinics any longer. The Affordable Care Act was never designed to be a universal healthcare option, a public option – an option where every single person in America was given an insurance card. Rather, it was to lower the barriers of health affordability for many people in the country. We know that this is not a public option, so that means that everyone is not going to have access. So as we’re looking at where the ACA is going to go in the future, free clinics are dealing with a couple of different issues when it comes to our patients. There are clinics who are located in states who have not expanded the Medicaid program. There are about 26 of those states across the country. Those states may or may not decide to have a model that is a different way to expand Medicaid than the one that was outlined in the bill. But currently in the states where there is no expansion of Medicaid, the patients will not have access to any of the subsidies or any of the programs that those living in expansion states do. As we’re looking at patients across the country, first and foremost, there is important education going on. If you think about it, having health insurance is confusing for those of us who have had health insurance our entire lives, never knowing what form to fill out, or whether your doctor is in-network or not in-network, if you are self-insured or your employer offers your healthcare plans. This is confusing for people who have had health insurance, imagine being someone who has never had health insurance before and you have no idea how to fill out what forms are needed for you or where you can go to the doctor. And then, even more so, imagine if you are a person who is eligible for the health insurance plans, but you have a job that doesn’t allow you to go to the doctor between 9:00 and 5:00. One of the things that Free and Charitable Clinics can offer as part of the safety net is sometimes our hours are different. They are the non-traditional hours that allow people to go to the clinics to get the care that they need and continue to be working. DIRECT RELIEF: Is there a difference for free clinics in the states that will expand "CHARITABLE CARE WILL REMAIN A VIABLE MODEL AS LONG AS WE DON’T HAVE UNIVERSAL HEALTHCARE. THERE WILL STILL BE PEOPLE WHO FALL THROUGH THE CRACKS. THAT’S OUR MANTRA—FILLING THE GAPS AND HELPING PEOPLE WHO FELL THROUGH THE CRACKS." —Beth Houghton, Executive Director, St. Petersburg Free Clinic, St. Petersburg, FL DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS // 9
  • 10. Medicaid and in states that won’t expand Medicaid? NICOLE LAMOUREUX: Clinics in states that are not expanding their Medicaid programs are definitely going to continue working in the same way that they have in the last couple of years, with an eye towards the future and what other clinics are doing in other locations. The reality of not expanding Medicaid means that you have a very similar patient base to what you have today, as opposed to those states that have expanded their Medicaid programs and their patient demographics may look a little different moving forward. However, I think what you are finding more clinics doing is looking at how to best serve the needs of their community. And what we are finding is we can look at clinics who have decided that it is the best interest of their community and their patient base to transition into a Federally Qualified Health Center role, where they will still serve the uninsured, but be able to take some funding from the federal government. Then we look at some of our clinics who have decided to take more of a charitable clinic role where, at this point in time, they are asking patients for a $5 payment towards their services, instead of free. We also then have clinics in states, regardless of whether Medicaid is expanding, who have said, “You know what? We need to be a hybrid clinic. We need to have an entire free clinic side of things, but we also need to start accepting some Medicaid patients as well.” Then I think you’re also looking at clinics who have said, “For right now, where we are in our communities and what we’re doing, we’re just going to remain free clinics.” That’s probably one of the most beautiful things about Free and Charitable Clinics is that we truly can be community built and grassroots built. We’re finding that clinics are looking at how to best serve their community and does the business model need to change, and how does that impact the mission of my organization all at one time? It’s a real growth and opportunity time for us, along with a challenge. DIRECT RELIEF: What are some of the opportunities or challenges the ACA presents free clinics? NICOLE LAMOUREUX: Well, I think definitely the opportunity that we see, and that we are hoping by telling the story of our clinics across the country and the amazing work that they do on a daily basis, we’re hoping to highlight how critical we are to the nation’s safety net. We are an essential piece to the safety net and that’s an opportunity, to tell the story of who’s left behind when it comes to the Affordable Care Act, the stories of the patients that are not going to receive coverage. Some of the challenges that we are addressing are not just for our clinics, but also for our patients: Whether or not people understand what the Affordable Care Act is, if someone gets an insurance card in their pocket, will there be a flooded healthcare system? Will there be a doctor to accept their health insurance? What about the hours of operation, as I talked about before? What about citizenship? Affordability of these programs that are there, especially in those states that did not expand their Medicaid programs? Transportation, how people are going to get to and from the doctor? Sometimes it’s great to have an insurance card in your pocket, but if you don’t have the $20.00 to go round trip to your doctor that becomes a challenge for you to get that health care. DIRECT RELIEF: Will charitable healthcare remain a relevant model? NICOLE LAMOUREUX: Again, one of the most common misconceptions about how the U.S. will look after the full implementation of the ACA, is that there will no longer be a need for our clinics to continue to provide charity care as a member of the safety net. People are surprised to hear that according to the Congressional Budget Office – there may be as many as 29 million people, including documented, undocumented, and those who are eligible for Medicaid, but reside in states that are not going to expand this program, who are still without access to health insurance. So we feel at the national level in the upcoming months and years, doctors and hospitals, navigators, states, and our clinics, as well as other members of the safety net, will be addressing the needs of the underserved with respect to affordability and accessibility of primary, specialty, dental care, and medication access. There will continue to be a need for charity care in the United States after the full implementation of the Affordable Care Act. 10 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS DirectRelief.org/USA
  • 11. “ If you’re at 200% of the Federal Poverty Level, you’re still way down in what you’re bringing in to live. In the Bay Area, by the time you pay for your car, food, and housing, people don’t have an extra $115 dollars in their pocket to see a doctor. They just refuse to pay it. We see a lot of those patients.” —RICHARD GIBBS, PRESIDENT AND CO-FOUNDER, SAN FRANCISCO FREE CLINIC, CA “ I ANTICIPATE THAT WE WILL BE SEEING A LARGE INCREASE IN THE NUMBER OF FOLKS WHO WILL COME TO SEE US, WHICH PRESENTS US WITH CHALLENGES.” —DAN AHEARN, CEO, COMMUNITY HEALTH ALLIANCE, RENO, NV “THE UNDOCUMENTED WON’T QUALIFY FOR THE EXCHANGES, AND THEY WON’T EVEN QUALIFY FOR MEDICAID, SO I STILL THINK THAT OUR 25% UNINSURED RATE WILL STAY RELATIVELY CONSTANT, AT LEAST UNTIL SOME OF THE IMMIGRATION DEBATES ARE ULTIMATELY DECIDED AMONG CONGRESS.” — Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY “THE WAITING LIST IS SO LONG THAT WE CAN’T EVEN BEGIN TO HANDLE IT – IT WILL GET MORE MANAGEABLE. MAYBE WE’LL BE ABLE TO SEE MORE OF THE PEOPLE ON OUR WAITING LISTS THAT GOES ON FOR MONTHS AND MONTHS AND MONTHS, AND WE’LL BE ABLE TO GIVE THOSE SMALLER GROUPS OF PEOPLE THAT ARE LEFT WITHOUT ACCESS THE MUCH NEEDED HEALTH CARE THAT THEY NEED." —Florence Jameson, Founder and CEO, Volunteers in Medicine of Southern Nevada, Las Vegas, NV DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS // 11
  • 12.  Sea Mar Community Health Center, Seattle, Washington THE PATIENTS People Cared for by the Safety Net PHOTO: DJORDJE ZLATANOVIC 12 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
  • 13. INCOME KNOWN INCOME LEVEL OF FQHC PATIENTS // 2013 Total patients = 16.3 million TOTAL FQHC PATIENTS, KNOWN INCOME LEVELS // 2009-2013 For the last five years the percent of individuals with incomes at or below 100% of the FPL seeking care at FQHCs has hardly varied (71.4-71.9%). While the percentage remained fairly stable, this is actually an aggregate increase from 10.1 million to 11.7 million individuals. 7.2% OVER 200% OF FPL 14.5% 101-150% OF FPL 6.4% 151- 200% OF FPL 71.9% AT OR BELOW 100% OF FEDERAL POVERTY LEVEL (FPL) The following provides an overview of demographic information from 2013 for the almost 22 million people treated annually at the nation’s Federally Qualified Health Centers (FQHCs).  21.7 MILLION TOTAL PATIENTS SERVED  7.6 MILLION PATIENTS (34.9%) LACKED HEALTH INSURANCE  Of individuals for whom income level was known, the vast majority (71.9%) were living at 100% or below of the Federal Poverty Level (FPL) – in 2013, that amounted to $11,490 for an individual and $23,550 for a family of four. The following charts show demographic information on patients at FQHCs in 2013, and what has changed compared to previous years. TOTAL PATIENTS IN MILLIONS 2009 2010 2011 2012 2013 AT OR BELOW 100% OF FPL 101-150% OF FPL 151-200% OF FPL OVER 200% OF FPL 0 5 10 15 20 71.4% 71.8% 71.8% 71.9% 71.9% “A SIGNIFICANT NUMBER OF PATIENTS THAT WE SERVE DON'T QUALIFY FOR MEDICARE OR MEDICAID AND DON'T QUALIFY FOR OUR COUNTY'S HEALTH PLAN, WHICH IS FOR THOSE WITH VERY LOW INCOMES. HAD MEDICAID BEEN EXTENDED UP TO A GIVEN INCOME LEVEL OUR ESTIMATE IS THAT A THIRD OF THE PATIENTS TRADITIONALLY SEEN BY OUR FREE CLINIC WOULD HAVE QUALIFIED FOR MEDICAID.” —Beth Houghton, Executive Director, St. Petersburg Free Clinic, St. Petersburg, FL DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 13
  • 14. INSURANCE INSURANCE SOURCE OF FQHC PATIENTS // 2013 Total patients = 21.7 million 34.9% NONE/UNINSURED 39.8% MEDICAID 14.1% PRIVATE 8.4% MEDICARE 2.0% PUBLIC 0 5 10 150 20 25 PATIENTS IN MILLIONS 2009 2010 2011 2012 2013 MEDICAID NONE/UNINSURED PRIVATE INSURANCE MEDICARE PUBLIC INSURANCE 38.2% 37.1% 37.5% 38.6% 36.4% 39.3% 36.0% 39.6% 34.9% 40.6% TOTAL PATIENTS, INSURANCE SOURCE // 2009-2013 From 2012 to 2013 not only did the uninsured percentage of patients seen at FQHCs decrease, but the aggregate number did as well, from 7.59 million to 7.57 million.* 2013 also saw an increase in patients using Medicaid, a continuation of the change seen in 2010 when Medicaid patients first exceeded uninsured patients. * The only other insurance category that decreased in both percentage and number was Other Public Insurance (non- Medicaid or Medicare). “OUR GUESS IS THAT WE WILL SEE STRONGER INFLUX OF THE WORKING POOR. WE WILL ALSO SEE PROBABLY ONLY ABOUT A 10% DROP, HOWEVER, IN OUR UNINSURED MEMBERS, AND WE ESTIMATE PERHAPS ONLY A 10% DROP IN WHAT’S CALLED OUR SELF-PAY CATEGORY, WHICH ARE PEOPLE WHO DON’T HAVE A LOT OF MONEY AND JUST PAY A SMALL PERCENTAGE OF WHAT THE ACTUAL VISIT COSTS.” —Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY 14 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
  • 15. "THERE’S A SIGNIFICANT PORTION OF OUR POPULATION THAT PROBABLY HAS NOT EVER BEEN INSURED IN THEIR ADULT LIFE." —RHONDA STUART, ENABLING SERVICES MANAGER, NORTHERN HEALTH CENTERS, LAKEWOOD, WI THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 15  Venice Family Clinic, Venice, California PHOTO: MARGARET MOLLOY DirectRelief.org/USA
  • 16. NUMBER OF PATIENTS = 21.7 MILLION FEMALE = 12.7 MILLION PATIENTS MALE = 9.0 MILLION PATIENTS AGE OF PATIENTS FQHC PATIENTS NATIONAL POPULATION 2013 65.2% 34.8% 16.3% 83.7% 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 A 2013 SNAPSHOT OF GENDER, RACE, AND AGE/GENDER OF FQHC PATIENTS // 2013 ETHNICITY AT FQHCs  Those aged 60-74 years were the fastest growing group as a proportion of the whole. This is a continued age increase from 2010 when the fastest growing group was those aged 50-64 years.  By gender, the five most common ages of patients seen at FQHCS were: Males 0-9 yrs (2,142,889) Females 20-29 yrs (2,128,691) Females 0-9 yrs (2,057,539) Females 30-39 yrs (1,887,387) Females 10-19 yrs (1,775,540)  The percentage of individuals identifying as White increased every year from 2008, 60.2% to 66.0% RACE OF FQHC PATIENTS // 2013 ETHNICITY OF FQHC PATIENTS // 2013 23.8% BLACK 66.0% WHITE 3.9% MORE THAN ONE RACE 3.6% ASIAN 1.4% AMERICAN INDIAN/ ALASKA NATIVE 1.3% HAWAIIAN/ PACIFIC ISLANDER NUMBER OF PATIENTS = 21.7 MILLION FEMALE = 12.7 MILLION PATIENTS MALE = 9.0 MILLION PATIENTS AGE OF PATIENTS FQHC PATIENTS NATIONAL POPULATION 2013 NOT HISPANIC/LATINO HISPANIC/LATINO 65.2% 34.8% 16.3% 83.7% 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 16 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS DirectRelief.org/USA
  • 17. “WE BELIEVE IT'S FAVORABLE BECAUSE, WE ARE ANTICIPATING ABOUT 3,000 OF OUR EXISTING PATIENTS WOULD BE ELIGIBLE FOR MEDICAID, FOR UP TO 133% OF THE FEDERAL POVERTY LEVEL. SO WITH THAT, WE ARE EXPECTING ABOUT 3,000, AT LEAST, OF OUR EXISTING PATIENTS WHO WILL GO FROM HAVING ZERO INSURANCE TO HAVING AN AFFORDABLE OPTION.” —Shondra Williams, CEO, Jefferson Community Health Care Centers, Marrero, LA “MOST OF THE PEOPLE WHO ARE NEWLY ELIGIBLE, WHICH WE ANTICIPATE WILL BE 125,000 SOUTHERN NEVADANS, IT'S NOT GOING TO HAPPEN LIKE THEY REGISTERED OVERNIGHT. THEY'RE GOING TO SHIFT SLOWLY IN THE NEXT YEAR OR TWO AS WE SHOW THEM THAT THEY'RE ELIGIBLE.” “Not everybody’s eligible, so it’s not going to completely eliminate the uninsured, so we still play a role. We’re better at dealing with some of these populations who have different needs. Certainly we have a lot of experience dealing with patients who don’t speak English, the chronically mentally ill, people with substance abuse issues, homeless people.” —TOM TOCHER, CHIEF CLINICAL OFFICER, COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY, EVERETT, WA "DOCTORS ARE SLOWLY NOT TAKING MEDICARE AND MEDICAID PATIENTS AND I DON'T KNOW WHAT WE'RE GOING TO DO BECAUSE THEY'RE GOING TO HAVE INSURANCE, OR MEDICARE, MEDICAID, AND AS THEY GET IT, THEY'RE NOT GOING TO BE ABLE TO UTILIZE IT BECAUSE I DON'T SEE A LOT OF NEW DOCTORS COMING ON." —JUDY JONES, EXECUTIVE DIRECTOR, BETHEL FREE HEALTH CLINIC INC., BILOXI, MS —FLORENCE JAMESON, FOUNDER AND CEO, VOLUNTEERS IN MEDICINE OF SOUTHERN NEVADA, LAS VEGAS, NV DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE PATIENTS // 17
  • 18. THE CONDITIONS A Look at the Quality of Care in the Nonprofit Safety Net PHOTO: MARGARET MOLLOY  Clínica Monseñor Oscar A. Romero, Los Angeles, California 18 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
  • 19. 2.4% ASTHMA 11.1% HYPERTENSION 22.8% SELECTED CHRONIC DISEASES 7.5% DIABETES 1.9% HEART DISEASE 77.2% ALL OTHER PRIMARY DIAGNOSES • CHILDHOOD CONDITIONS • COMMUNICABLE DISEASES • DENTAL SERVICES • DIAGNOSTIC TESTS • MENTAL HEALTH & SUBSTANCE ABUSE CONDITIONS • NONCOMMUNICABLE DISEASES • PREVENTIVE SERVICES • SCREENINGS • OTHER SELECTED DIAGNOSES [ ] In 2011 the Health Resources and Services Administration changed the way in which diagnoses at Federally Qualified Health Centers were tracked to include all diagnoses at a visit, regardless of primacy. Previously only the primary diagnosis was used to estimate percent of patients with a condition or for tracking number of visits. The change, however, took into account that primary diagnosis alone likely underestimates the morbidity and burden of certain conditions for the patients and for the health centers. This hypothesis is carried out when comparing the data on total visits by diagnosis from 2011, for which the data showed 12.3% of visits were related to hypertension, diabetes, heart disease and asthma, and 2013, for which the new calculation gives 22.8% for the same four conditions. The new data collection parameters already show a greater number of patients than previously estimated for all tracked diagnoses, giving a more accurate portrayal of the burden on FQHCs for service provision. Particularly with chronic conditions, which account for a large percentage of total services provided, there is an even greater stress placed on clinics due to these conditions requiring services over a longer period of time. It is thus up to FQHCs to provide high quality care to a growing population of patients with increasing needs. 22% OF ALL FQHC VISITS ARE RELATED TO SELECTED CHRONIC DISEASES // 2013 “WE’RE EXCITED BECAUSE OUR PATIENTS WHO HAVE BEEN STRUGGLING WITHOUT INSURANCE FOR SO LONG, THIS IS AN OPPORTUNITY FOR THEM TO GET CARE AND TAKE CARE OF SOME OF THE THINGS THEY’VE PROBABLY BEEN PUTTING OFF.“ —Tom Tocher, Chief Clinical Officer, Community Health Center of Snohomish County, Everett, WA DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 19
  • 20. QUALITY OF CARE DATA DIFFERENCE BETWEEN FQHC AND STATE HYPERTENSION RATES Safety-net health facilities, such as the Federally Qualified Health Centers, play a critical role in providing care for at least 1 in 13 Americans. As part of a health network caring for under- and uninsured working class poor that do not otherwise have access to health care it is important that not only do the services exist, but that they are of the highest standards. Indeed, a 2011 study conducted by Randall Stafford, MD, PhD of Stanford University found that despite treating significantly more “medically and socially complex patients” than those seen by private providers, community health centers actually provide “better care than do private practices.” From 2010-2013 FQHCs saw the percentage of adults aged 18 and older with a hypertension diagnosis increase by 11.0%. In fact, hypertension as a primary or related diagnosis accounted for more visits in 2013 than any other condition, a total of 9,472,375. While the rate of FQHC patients with hypertension is increasing, the patient population at these safety-net facilities tend to actually have a lower rate than for the state population. Despite the increasing burden of hypertension, FQHCs have shown to provide the utmost in quality of care for patients. Stafford’s study identified blood pressure screening as one of six measures that FQHCs and FQHC Look- Alikes performed better on than private primary care practices. As well, almost all state FQHC populations have met the United States’ Healthy People 2020 Target of 61.2% of adults with a hypertension diagnosis considered controlled. Fiftteen states have not yet met the Target, but even the state with the lowest percentage of controlled hypertension, Arkansas, is only 5.3 percentage points away, with five years remaining. HIGHEST AND LOWEST RATES OF CONTROLLED BLOOD PRESSURE IN THE FQHC POPULATION // 2013 NEW HAMPSHIRE VERMONT 82.90% 82.90% 80.60% 68.90% 59.90% 56.10% 46.70% NORTH DAKOTA USA HAWAII DELAWARE WYOMING 0 20 40 60 80 100 72.50% 70.60% 69.90% 63.60% 58.70% 56.60% 55.90% VERMONT MAINE PENNSYLVANIA USA MISSOURI ALABAMA ARKANSAS 0 10 20 30 40 50 60 70 80 CONTROLLED BLOOD PRESSURE AT FQHCs // 2013 States colored in blue have a lower rate of diagnosed hypertension at FQHCs than the rate for that respective state. States in red scale have a greater rate of diagnosed hypertension at FQHCs. Healthy People 2020 lists controlled hypertension as a Leading Health Indicator. The Target is 61.2% of adults with a hypertension diagnosis considered controlled. Thirty-five states have met the Target within the FQHC population. 20 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
  • 21. "I feel like IT'S DEFINITELY GOING TO CHANGE THE OVERALL HEALTH OF AMERICA. For countries that have universal health coverage, patients don't wait to seek care. There's a reduction of chronic disease because there's prevention and early detection. It's going to be the same for America down the road." —SHANE CHEN, CHIEF OPERATIONS OFFICER, ASIAN AMERICAN HEALTH COALITION CLINIC, HOUSTON, TX  Venice Family Clinic, Venice, California PHOTO: MARGARET MOLLOY DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 21
  • 22. DIFFERENCE BETWEEN FQHC AND STATE DIABETES RATES HIGHEST AND LOWEST RATES OF CONTROLLED DIABETES IN THE FQHC POPULATION // 2013 NEW HAMPSHIRE VERMONT 82.90% 82.90% 80.60% 68.90% 59.90% 56.10% 46.70% NORTH DAKOTA USA HAWAII DELAWARE WYOMING 0 20 40 60 80 100 CONTROLLED DIABETES AT FQHCs // 2013 A condition that has a similar weight on safety net resources is diabetes. Of note is that diabetes is over represented amongst FQHC patients compared to the rest of the US population. The rate of diagnosed diabetes among adults aged 18 and older is higher in the FQHC population in all but one state. As many FQHCs continue to see an increase in the proportion of patients with controlled diabetes, they are also thus faced with a greater demand for services and medication. No state has yet met the Healthy People 2020 Target of 83.9% of adults with a diabetes diagnosis considered controlled. The over burden of diabetes exemplifies the need for support and resources to enable safety-net facilities to provide and expand quality care for all their patients. These quality of care measures for chronic diseases are important as if these intermediate outcomes are improved, then later poor health outcomes will be far less likely. Direct Relief USA works with more than 1,200 clinic partners across the country, more than half of which are Federally Qualified Health Centers like the ones studied. The report from Stanford and the collected FQHC data confirm that the patients Direct Relief’s clinic partners serve can access quality care from what many acknowledge is an already-strained network caring for a disproportionate share of socially vulnerable and chronically ill patients. “These are centers where physicians are not as profit-driven and many have incentives more in line with providing quality care,” said Dr. Stafford. States colored in blue have a lower rate of physician diagnosed diabetes at FQHCs than the rate for that respective state. States in red scale have a greater rate of diagnosed diabetes at FQHCs. Healthy People 2020 lists controlled diabetes (Hb A1c <9%) as a Leading Health Indicator. The Target is 83.9% of adults with a diabetes diagnosis considered controlled. No state has yet met the Target within the FQHC population. 22 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS DirectRelief.org/USA
  • 23. " I THINK THE ACA WILL HELP PEOPLE HAVE ACCESS TO SPECIALISTS THAT PREVIOUSLY THEY DID NOT HAVE ACCESS TO." —BARB TYLENDA, EXECUTIVE DIRECTOR, HEALTH CARE NETWORK, RACINE, WI "THERE ARE THOSE WHO THINK THAT THERE WON'T BE A NEED FOR FREE CLINICS. I THINK NOTHING COULD BE FARTHER FROM THE TRUTH. I'M BANKING ON THE FACT THAT WE'RE GOING BE NEEDED, AND WE'RE GOING HAVE A LOT OF PEOPLE WHO STILL NEED ASSISTANCE AND WE'RE GOING BE ABLE TO CARE FOR THEM." —Jim Harris, CEO, Health Access Incorporated, Clarksburg, WV “WILL IT IMPROVE PATIENTS OVERNIGHT? NO. I THINK IT’S GOING TO TAKE SEVERAL YEARS TILL WE CAN REALLY SAY HAVING ACCESS INCREASES OR DOES NOT INCREASE THE HEALTH STATUS.” —Dan Ahearn, CEO, Community Health Alliance, Reno, NV "IT’S GREAT TO HAVE INSURANCE. DON’T GET ME WRONG. BUT YOU STILL HAVE TO HAVE ACCESS TO CARE. AND FOR OUR SICK PATIENTS, THE ONES THAT ARE UNINSURED, YOU HAVE TO HELP THEM UNDERSTAND HOW IMPORTANT IT IS TO TAKE CARE OF YOURSELF WHEN YOU HAVE CHRONIC DISEASES." —ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, WILLIAM F. RYAN COMMUNITY HEALTH CENTER, NEW YORK, NY DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS // 23
  • 24. THE COMMUNITIES Medicaid and the Nonprofit Safety Net PHOTO: GREG DAVIS  Sea Mar Community Health Center, Seattle, Washington 24 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
  • 25. A DEEPER DIVE INTO THE ROLE OF THE SAFETY NET DURING MEDICAID EXPANSION – AND IN STATES WITHOUT MEDICAID EXPANSION As of September 2014 the preeminent issue for understanding the impact of the ACA upon uninsured people across the country remains the status of their state relative to the Medicaid expansion portion of the law. According to a study published in Health Affairs1 along with related studies published by RAND2 and the Kaiser Family Foundation3, there are likely an estimated 8 million individuals living in the 25 states which are not expanding Medicaid who would be newly insured this year had their states opted in to the Medicaid expansion provisions of the ACA. Almost all of these individuals will remain uninsured, given that their incomes will likely remain too low to qualify for the health insurance exchange subsidies, yet not low enough to fall within prior Medicaid qualifications. Subsidy amounts were set at a minimum of 138 percent of the Federal Poverty Level (FPL) for a family of three, under the assumption that Medicaid expansion would take care of coverage for those households and individuals between 100 percent and 138 percent of FPL. Among those nearly 8 million uninsured individuals exist hundreds of thousands of cases of depression, diabetes, and other chronic illnesses which will likely require some form of charitable mechanism to address. The most incisive study to date on the possible impact of the uneven Medicaid expansion landscape on the health of people without insurance was published by JAMA in April 20144. According to the authors’ interpretation of health data collected from a national pool of roughly 19,000 persons living under the 138% FPL threshold, chronic conditions such as hypertension, cancer, stroke, and respiratory diseases were significantly more prevalent amongst those living in non-expansion states. In other words, poor residents of non-expansion states will not only be unlikely to receive additional assistance from the ACA with improved access to healthcare payments, but are also already in poorer CURRENT STATUS OF MEDICAID EXPANSION DECISION Implementing Expansion in 2014 Not Moving Forward at this Time 1 (http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and- financial-impacts/) DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 25
  • 26. LAS VEGAS, NV NEW ORLEANS, LA health than their counterparts in Medicaid expansion states. Granted, health insurance in itself does not guarantee access to quality healthcare. Yet the best evidence available indicates that where you live in the future may play an even greater role in the health outcomes than it has so far. Local, just as much as national, landscapes of care are shaped by the conditions of place. Cities like Las Vegas, NV and New Orleans, LA face very similar challenges in the post-ACA world. The populations of these cities are of similar population size and income distributions. Both have dealt with significant challenges over the past several years: Las Vegas through the crisis in the housing market and the pressures of economic recession, New Orleans with the aftershocks of Hurricane Katrina and their own recessionary trends since 2008. Mapping the census blocks of each city according to the ACA’s new Medicaid eligibility levels (138% FPL) in relation to the locations of safety net facilities reveals high densities of proximate neighborhoods with high likelihood of significant numbers of newly insured people. Yet, of course, these landscapes mean very different things in 2014 based upon differences in approach at the state level to the ACA. In Las Vegas, given that Nevada is participating in the Medicaid expansion, census blocks with median income levels of 138% FPL and below will be likely to put pressure on the safety net through increases in new Medicaid patients. In New Orleans, however, given Louisiana’s opposition to the Medicaid expansion, this very same landscape is one which indicates persistent uninsured levels and sizeable ongoing gaps in the ability to pay for healthcare services. In each case, safety net institutions face significant pressures, but the nature of those pressures differs markedly depending on where they occur and how their states have chosen to approach the implementation of the ACA. 2 (http://www.rand.org/health/aca/medicaid_expansion.html) 3 (http://kff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/) 4 (https://archinte.jamanetwork.com/article.aspx?articleid=1857090) 26 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
  • 27. “WE KNOW A LITTLE OVER 90,000 PEOPLE IN OKLAHOMA COUNTY ARE UNINSURED AND HAVE A HOUSEHOLD INCOME AT 200 PERCENT FEDERAL POVERTY LEVEL. WE WERE REALLY HOPEFUL THAT, IF EVEN A THIRD OF THEM WERE ABLE TO MOVE ONTO MEDICAID AND HAVE A PAYMENT SOURCE THAT IT WOULD MAKE A HUGE DIFFERENCE IN OUR WORKLOAD. THAT’S NOT HAPPENING… SO UNFORTUNATELY, WHEREAS WE THOUGHT THINGS MIGHT BE IMPROVING FOR OUR POPULATION IT’S NOT GOING TO IMPROVE VERY MUCH.” —PAM CROSS-CUPIT, EXECUTIVE DIRECTOR, HEALTH ALLIANCE FOR THE UNINSURED, OKLAHOMA CITY, OK " MY GUT FEELING IS THAT THERE STILL WILL BE A SIGNIFICANT NUMBER OF UNINSURED IN NEW YORK CITY BECAUSE WE HAVE SO MANY UNDOCUMENTED FOLKS LIVING IN NEW YORK CITY. WE’LL STILL BE SERVING THOSE PATIENTS, BUT THEY STILL WON’T HAVE INSURANCE, BUT THEY’LL STILL COME TO THE FQHCS." —ANA TARAS, CHIEF OF STRATEGIC INITIATIVES, WILLIAM F. RYAN COMMUNITY HEALTH CENTER, NEW YORK, NY “NOT MANY PRIMARY CARE DOCTORS’ OFFICES ARE GOING TO BE ABLE TO TAKE IN A LARGE AMOUNT OF MEDICAID PATIENTS BECAUSE EVEN THOUGH SOME OF THE MEDICAID PATIENT’S PAYMENTS MAY GO UP TO MEDICARE LEVELS IT’S DIFFICULT TO KEEP THE LIGHTS ON AND THE DOORS OPEN WITH THAT.” —Dan Ahearn, CEO, Community Health Alliance, Reno, NV " The greatest challenge is with the hospital acute care centers. There are, in Louisiana specifically, and more importantly, in our parish, two major hospitals that are considering closing or being purchased by a new entity, and it’s because they're unsure of their financial feasibility in the climate where their disproportionate funds are going to be reduced or eliminated as a result of ACA." —Shondra Williams, CEO, Jefferson Community Health Care Centers, Marrero, LA DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 27
  • 28. Community health centers are experiencing in 2014 an overall increase nationwide in people seeking care at their facilities, but a decrease in people who are uninsured. This finding accords with a number of other recent indicators showing that the ACA does appear to be reducing uninsured rates nationally. However, Direct Relief’s poll also shows that the impact of the ACA is highly variable based upon geography. Respondents in states which are not expanding the Medicaid program overwhelmingly reported that their uninsured rates have actually been increasing, whereas the opposite was true in states which have undertaken Medicaid expansion. Respondents from states that have adopted expanded Medicaid eligibility authorized under the Affordable Care Act also indicated that they hold a substantially more favorable view of the law’s impact than those in non-expansion states. These findings come from a poll of nearly 100 community health centers conducted by Direct Relief in August 2014 at the annual conference of the National Association of Community Health Centers. Survey respondents collectively serve more than 1.5 million people and operate clinical sites in 27 U.S. states. FLASH POLL: COMMUNITY HEALTH & MEDICAID EXPANSION 2014 COMMUNITY HEALTH INSITITUTE & EXPO MEDICAID EXPANSION STATE 48.0% MEDICAID EXPANSION STATE NON-EXPANSION STATES IN DEBATE NON-EXPANSION STATE 46.4% IN DEBATE 5.4% 0 2 4 6 8 10 12 IN MILLIONS 1,120,000 353,000 37,000 MEDICAID EXPANSION STATE 48.0% MEDICAID EXPANSION STATE NON-EXPANSION STATES IN DEBATE NON-EXPANSION STATE 46.4% IN DEBATE 5.4% 0 2 4 6 8 10 12 IN MILLIONS 1,120,000 353,000 37,000 RESPONDENT LOCATION PATIENTS REPRESENTED BY RESPONDENTS 28 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES DirectRelief.org/USA
  • 29. 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 81.5% 3.7% 14.8% 76.9% 64.0% 16.0% 20.0% 58.3% 16.7% 25.0% 19.2% 3.8% 19.2% 96.3% 0.0% 3.7% 50.0% 30.8% INCREASE DECREASE NO CHANGE INCREASE DECREASE NO CHANGE POSITIVELY NEGATIVELY NO CHANGE INCREASE DECREASE NO CHANGE INCREASE DECREASE NO CHANGE POSITIVELY NEGATIVELY NO CHANGE 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 81.5% 3.7% 14.8% 76.9% 64.0% 16.0% 20.0% 58.3% 16.7% 25.0% 19.2% 3.8% 19.2% 96.3% 0.0% 3.7% 50.0% 30.8% INCREASE DECREASE NO CHANGE INCREASE DECREASE NO CHANGE POSITIVELY NEGATIVELY NO CHANGE INCREASE DECREASE NO CHANGE INCREASE DECREASE NO CHANGE POSITIVELY NEGATIVELY NO CHANGE IN 2014 SO FAR, HAS YOUR FACILITY SEEN A CHANGE IN THE TOTAL NUMBER OF PATIENTS? IN 2014 SO FAR, HAS YOUR FACILITY SEEN A CHANGE IN THE TOTAL NUMBER OF PATIENTS WITHOUT INSURANCE? HOW DO YOU THINK THE AFFORDABLE CARE ACT, OVERALL, HAS AFFECTED YOUR FACILITY? STATES EXPANDING MEDICAID STATES NOT EXPANDING MEDICAID DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES // 29
  • 30. BACKGROUND Direct Relief USA and the Safety Net PHOTO: MARGARET MALLOY  Clínica Monseñor Oscar A. Romero, Los Angeles, California 30 // THE STATE OF THE SAFETY NET 2014 // BACKGROUND DirectRelief.org/USA
  • 31. Since 1948, Direct Relief has provided humanitarian assistance to improve the health and quality of life of people affected by poverty and disasters throughout the world by providing essential material resources—medicine, medical supplies, and basic equipment. Direct Relief is the nation’s leading nonprofit provider of donated medicines to community clinics, free clinics, and community health centers for low-income patients without health insurance. It operates the largest charitable medicines program of its kind, and is the only nonprofit that is certified by the National Association of Boards of Pharmacy to distribute prescription medicine in all 50 states. Since 2004, Direct Relief has delivered more than $440 million (wholesale) in medical resources to more than 1,200 nonprofit clinic and health centers. Direct Relief is recognized for its fiscal strength, accountability and efficiency, and consistently achieves top rankings from Forbes, Charity Navigator (including “Top Charity” and “4-Stars”), the Better Business Bureau, and Consumers Digest. In 2011, Forbes rated Direct Relief “100% efficient” and “[Among the] 20 most efficient large U.S. charities.” BASED ON DAILY INTERACTION WITH PARTNERS, DIRECT RELIEF REQUESTS NEEDED MEDICAL PRODUCTS FROM 150 HEALTHCARE COMPANIES. DIRECT RELIEF NOTIFIES CLINIC AND HEALTH CENTER PARTNERS OF AVAILABLE PRODUCTS THROUGH THE DIRECT RELIEF NETWORK. CLINICS CAN PLACE A REQUEST FOR DONATED PRODUCTS FOR THEIR LOW-INCOME PATIENTS WITHOUT HEALTH INSURANCE. PRODUCTS ARE DELIVERED TO THE PARTNERS COURTESY OF FEDEX, FREE OF CHARGE, TO BE GIVEN TO PATIENTS. DIRECT RELIEF PHARMACISTS REVIEW ALL PRODUCT REQUESTS AND ADJUST AS NECESSARY BASED ON THE AVAILABILITY OF REQUESTED PRODUCTS AND THE INFORMATION CLINICS PROVIDE ABOUT THEIR HEALTH FACILITIES. Rx DIRECT RELIEF’S CLINIC AND HEALTH CENTER PARTNER NETWORK 11 million patients 55.4% FQHC/LOOK-ALIKE 608 FQHC/LOOK-ALIKE 34.3% FREE CLINIC 9.7% COMMUNITY CLINIC 99 COMMUNITY CLINIC X% PUBLIC HEALTH DEPARTMENT 4 PUBLIC HEALTH DEPARTMENT X% OTHER 53 SOCIAL SERVICES 398 FREE CLINIC 9 OTHER HOW IT WORKS DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // BACKGROUND // 31
  • 32. METHODOLOGIES // DATA SOURCES HEALTH RESOURCES AND SERVICES ADMINISTRATION Uniform Data System The information presented here applies to those entities from which the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) collects data through the Uniform Data System (UDS). These are grantees of the following HRSA primary care programs: Community Health Centers, Health Care for the Homeless, and Public Housing Primary Care providers. Grantees can be found in all 50 states, the District of Columbia, and U.S. territories. The reported data should not be extrapolated to any other population as it is representative only of those individuals who utilize services of FQHC grantees. Please note that rates of diagnoses, insurance levels, demographics, etc. are descriptive measurements to provide context and are not intended for the sake of population-level analysis or comparison with institutions that are not nonprofit safety-net health centers and clinics. For example, a particular health center might show that a high percentage of its patient population consists of homeless individuals. This does not necessarily mean that the area in which it operates has an exceptionally high rate of homelessness. Rather, the health center may have specific programs and outreach aimed at bringing health care to homeless individuals. Such a program therefore would skew the facility’s patient population numbers not only away from the norm of its service area, but also from levels seen at FQHCs without such programs. Likewise, disease diagnosis rates recorded at these institutions should not be mistaken for disease prevalence rates among the area’s general population. It should also be noted, however, that all FQHCs are located by law in areas that are deemed by the federal government to be medically underserved. COMMUNITY HEALTH INSTITUTE AND EXPO FLASH POLL – During the 2014 Community Health Institute and Expo hosted by the National Association of Community Health Centers, Direct Relief surveyed attendees regarding their perceptions related to health centers, their patient population, and the Affordable Care Act. The survey was a total of six questions and each respondent represented an individual from a health center. Fifty-six responses were garnered from this population from August 23-24, 2014. © Direct Relief 2014 All rights reserved. Requests for permission to reproduce should be addressed to Direct Relief, 27 South La Patera Lane, Santa Barbara, CA, 93117. Phone: (800) 676-1638; fax: (805) 681-4838; email: info@directrelief.org. Authors Andrew Schroeder, PhD, MPP; Damon Taugher; Thomas Tighe; Jennifer Lemberger, MPH Art Direction Andrew Fletcher Design Leslie Lewis Sigler, studio-sigler.com METHODOLOGIES 32 // THE STATE OF THE SAFETY NET 2014 // METHODOLOGIES DirectRelief.org/USA
  • 33. VOICES OF THE SAFETY NET Interviews took place with nonprofit safety-net clinic and health center staff, as well as national associations from August 2013 – March 2014. Quotes from the following interviews are included in this report: Dan Ahearn, CEO, Community Health Alliance, Reno, NV Jane Calhoun, VP Medical Affairs & Clinical Director, Delta Health Alliance, Stonesville, MS Shane Chen, Chief Operations Officer, Asian American Health Coalition Clinic, Houston, TX Pam Cross-Cupit, Executive Director, Health Alliance for the Uninsured, Oklahoma City, OK Alieta Eck, Founder, Zarepath Health Center, Somerset, NJ Richard Gibbs, President and Co-Founder, San Francisco Free Clinic, San Francisco, CA Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY Jim Harris, CEO, Health Access Incorporated, Clarksburg, WV Beth Houghton, Executive Director, St. Petersburg Free Clinic, St. Petersburg, FL Florence Jameson, Founder and CEO, Volunteers in Medicine of Southern Nevada, Las Vegas, NV Judy Jones, Executive Director, Bethel Free Health Clinic Inc., Biloxi, MS Rhonda Stuart, Enabling Services Manager, Northern Health Centers, Lakewood, WI Ana Taras, Chief of Strategic Initiatives, William F. Ryan Community Health Center, New York, NY Tom Tocher, Chief Clinical Officer, Community Health Center of Snohomish County, Everett, WA Barb Tylenda, Executive Director, Health Care Network, Racine, WI Shondra Williams, CEO, Jefferson Community Health Care Centers, Marrero, LA Nicole Lamoureux, Executive Director National Association of Free and Charitable Clinics, Alexandria, VA “HEALTH INSURANCE IS A CARD ISSUED BY THE STATE AND DOES NOT GUARANTEE ACCESS TO MEDICAL CARE. IF THERE ARE NO DOCTORS TO TAKE IT…CHARITY CARE WILL REMAIN A VERY VIABLE OPTION, AND THE THING ABOUT HEALTH INSURANCE—SOMEHOW WE’VE BOUGHT THE LIE THAT EVERYBODY NEEDS HEALTH INSURANCE TO GET MEDICAL CARE, WHEN SOMEBODY WITHOUT ACCESS DOES NOT NEED INSURANCE. WHAT THEY NEED IS A PLACE TO GO WHEN THEY FIND THEMSELVES SICK AND IN NEED OF MEDICAL CARE, AND WITHOUT ANY FUNDS.” — Alieta Eck, Founder, Zarepath Health Center, Somerset, NJ DirectRelief.org/USA THE STATE OF THE SAFETY NET 2014 // METHODOLOGIES // 33
  • 34. > LEARN MORE DirectRelief.org/USA Learn more about Direct Relief’s work throughout the United States and see an interactive map of the medical support Direct Relief provides to over 1,200 health centers and clinics. > MAKE A DONATION DirectRelief.org/donate Direct Relief is a private, charitable organization that does not receive government funding and depends on the generous support of private businesses, individuals, and grantmaking organizations to improve access to essential health services in the United States and worldwide. > FOR PRESS/MEDIA INQUIRIES Contact Kerri Murray at (800) 676-1638, or kmurray@directrelief.org. LEARN MORE ABOUT THE SAFETY NET // DIRECTRELIEF.ORG/USA > DIRECT RELIEF 27 South La Patera Lane Santa Barbara, CA 93117 USA (800) 676-1638 PHOTO: ANDREW FLETCHER 34 // THE STATE OF THE SAFETY NET 2014 // LEARN MORE DirectRelief.org/USA