state of the safety net 2014

THE STATE OF THE SAFETY NET 2014Healthcare Reform and the Safety Net

PH

OTO

: MA

RG

AR

ET M

OLL

OY

�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

WIL

LIA

M V

AZQ

UEZ

FO

R A

BB

OTT

FU

ND

CONTENTS

DirectRelief.org/USA2 // THE STATE OF THE SAFETY NET 2014 // CONTENTS

PH

OTO

: MA

RG

AR

ET M

OLL

OY

WIL

LIA

M V

AZQ

UEZ

FO

R A

BB

OTT

FU

ND

"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


THE STATE OF THE SAFETY NET 2014 // CONTENTS // 3DirectRelief.org/USA

PH

OTO

: CH

ASS

T he 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

DirectRelief.org/USA4 // THE STATE OF THE SAFETY NET 2014 // INTRODUCTION

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.

PH

OTO

: CH

ASS

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.

DirectRelief.org/USA6 // THE STATE OF THE SAFETY NET 2014 // TERMINOLOGY

"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

PH

OTO

: MA

RG

AR

ET M

OLL

OY

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

PH

OTO

: CH

ASS

DirectRelief.org/USA8 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS

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.

DirectRelief.org/USA10 // THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS

“ 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

THE STATE OF THE SAFETY NET 2014 // THE PROVIDERS // 11DirectRelief.org/USA

�Sea Mar Community Health Center, Seattle, Washington

THE PATIENTS

People Cared for by the Safety Net

PH

OTO

: DJO

RD

JE Z

LATA

NO

VIC

DirectRelief.org/USA12 // THE STATE OF THE SAFETY NET 2014 // THE PATIENTS

INCOMEKNOWN 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)

T he 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.

TOTA

L P

ATIE

NTS

IN

MIL

LIO

NS

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

71.8%71.4% 71.8% 71.9% 71.9%

PH

OTO

: DJO

RD

JE Z

LATA

NO

VIC

“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

INSURANCEINSURANCE 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

PAT

IEN

TS I

N M

ILL

ION

S

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


"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

PH

OTO

: MA

RG

AR

ET M

OLL

OY

DirectRelief.org/USA

NUMBER OF PATIENTS = 21.7 MILLION

FEMALE = 12.7 MILLION PATIENTS MALE = 9.0 MILLION PATIENTS

AG

E O

F P

ATIE

NTS

FQHC PATIENTS NATIONAL POPULATION 2013

NOT HISPANIC/LATINO

HISPANIC/LATINO

34.8%65.2%16.3%

83.7%

0 200,000 400,000 600,000 800,000 1,000,000 1,200,000200,000400,000600,000800,0001,000,0001,200,000

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

AGE/GENDER OF FQHC PATIENTS // 2013A 2013 SNAPSHOT OF GENDER, RACE, AND 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%

ETHNICITY OF FQHC PATIENTS // 2013RACE 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

AG

E O

F P

ATIE

NTS

FQHC PATIENTS NATIONAL POPULATION 2013

NOT HISPANIC/LATINO

HISPANIC/LATINO

34.8%65.2%16.3%

83.7%

0 200,000 400,000 600,000 800,000 1,000,000 1,200,000200,000400,000600,000800,0001,000,0001,200,000

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


“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

PH

OTO

: MA

RG

AR

ET M

OLL

OY


DirectRelief.org/USA18 // THE STATE OF THE SAFETY NET 2014 // THE CONDITIONS

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.


"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 PH

OTO

: MA

RG

AR

ET M

OLL

OY


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

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 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.


" 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


THE COMMUNITIES

Medicaid and the Nonprofit Safety Net

PH

OTO

: GR

EG D

AVIS

�Sea Mar Community Health Center, Seattle, Washington

DirectRelief.org/USA24 // THE STATE OF THE SAFETY NET 2014 // THE COMMUNITIES

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)


“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


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 EXPANSION2014 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 M

ILL

ION

S

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 M

ILL

ION

S

1,120,000

353,000

37,000

RESPONDENT LOCATION

PATIENTS REPRESENTED BY RESPONDENTS


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


U.S

. NAT

ION

AL

OC

EAN

IC A

ND

ATM

OSP

HER

IC A

DM

INIS

TRAT

ION

BACKGROUND

Direct Relief USA and the Safety Net

PH

OTO

: MA

RG

AR

ET M

ALL

OY


DirectRelief.org/USA30 // THE STATE OF THE SAFETY NET 2014 // BACKGROUND

S ince 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

608FQHC/LOOK-ALIKE

34.3%FREE CLINIC

9.7%COMMUNITY

CLINIC

99COMMUNITY CLINIC

X%PUBLIC HEALTH

DEPARTMENT

4PUBLIC HEALTH

DEPARTMENT

X%OTHER

53SOCIAL SERVICES

398FREE CLINIC

9OTHER

HO

W IT

WO

RK

SDirectRelief.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: [email protected].

Authors

Andrew Schroeder, PhD, MPP;

Damon Taugher; Thomas Tighe;

Jennifer Lemberger, MPH

Art Direction

Andrew Fletcher

Design

Leslie Lewis Sigler, studio-sigler.com

METHODOLOGIES

DirectRelief.org/USA32 // THE STATE OF THE SAFETY NET 2014 // METHODOLOGIES

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 [email protected].

LEARN MORE ABOUT THE SAFETY NET // DIRECTRELIEF.ORG/USA

> DIRECT RELIEF 27 South La Patera Lane

Santa Barbara, CA 93117 USA

(800) 676-1638

PH

OTO

: AN

DR

EW F

LETC

HER

DirectRelief.org/USA34 // THE STATE OF THE SAFETY NET 2014 // LEARN MORE