1. Anthony T. Lo Sasso, PhD Gayle R. Byck, PhD University of Illinois at Chicago Thanks to NICHD for grant support

2. Background FQHCs make up the “front line” of the health care safety net In 2006 nearly 6 million (40%) of FQHCs' 15 million patients were uninsured another 5.3 million (35%) were Medicaid recipients ~25% of the nation’s 3.4 million low-income uninsured children receive care at an FQHC

3. Policy Change The Health Centers Initiative (2002) increased federal funding for FQHCs from just over $1 billion in 2001 to nearly $2 billion in 2007 Number of health centers increased from roughly 750 centers in 2001 to the recently reached milestone of 1200 centers in December 2007 However, there has been little research examining how the additional funds have affected service provision at FQHCs

4. Our Goal By carefully modeling the relationship between Federal grant dollars (as well as other revenue sources) and several important clinic-level service measures, our research sheds light on what the return has been on the investment of expanded federal grant support for FQHCs

5. Outcomes we hypothesize will be affected by increased grant support General scope of service (number of sites of operation, 24 hour coverage, emergency medical care, and urgent medical care) The scope of service measures allow us to gauge the reach of the FQHC and at least implicitly its ability to provide services to populations in need Behavioral health care services (mental health treatment and counseling, 24 hour crisis intervention and counseling, and substance abuse treatment and counseling) Behavioral health services have recently been recognized as a critical need in communities as public and private psychiatric hospital closures have accelerated throughout the 1990s Uncompensated care (UC) provision

6. Number of FQHCs Over Time

7. Mean Federal, State/Local, & Private/Foundation Grants

8. Mean provision of on-site 24-hour coverage and urgent care

9. Mean number of sites per FQHC

10. Mean provision of on-site behavioral health services

11. Mean uncompensated care provision

12. We use panel data multivariate methods to control for other stuff The model is specified as: Outcome ct = α + β 1 Grants ct + β 2 X ct + γ c + δ t + ε ct Where c references the FQHC and t is time The coefficients of interest are β 1 which reflect the effect of grant dollars on the outcome variable We control for other factors that might be related to the outcomes of interest (age, race, insurance status, and income distribution of clinic patients), plus FQHC fixed effects and time fixed effects

13. Summary Multivariate Results Federal Grants ($M) State/Local Grants ($M) Private Grants ($M) Number of Sites 1.5011***0.2947***0.8429*** 24 hour coverage 0.0116***0.00140.0193** Mental health treatment/counseling 0.0321***-0.00010.0014 24 hour crisis intervention 0.0138**0.0094**0.0154 Substance use treatment/counseling 0.0356***0.0026-0.0128 Uncompensated Care ($millions) 0.2669***0.1506***0.2243**

14. Discussion and Policy Exercises Our results suggest that the recent investments made in FQHCs impacted service provision along a number of important margins To put the UC result in perspective, a hypothetical $500,000 increase in federal grant funding for the average clinic (which roughly corresponds to the average increase in federal grant funding observed between 1996 and 2001) is predicted to increase UC by $135,000 per clinic Mean UC per uninsured patient was roughly $250, thus the additional $135,000 in UC translates into 540 more uninsured patients treated, on average, per FQHC, or about a 10% increase in treatment of uninsured patients

15. Discussion and Policy Exercises Scaling the estimates up to the entire FQHC program, a hypothetical $500,000 increase in grant support for each FQHCs would cost roughly $.5 billion, but treat an additional 500,000 uninsured patients in addition to allowing FQHCs to offer additional services important to communities We also find suggestive results that FQHCs are able to leverage their federal grant support in order to gain additional state, local, and private grant dollars, which lead to still higher levels of service and UC provision

16. Conclusion The recent Health Centers Initiative would appear to have been a wise investment, though the ultimate proof is in the extent to which population health is improved, which is beyond the scope of this study As a final note of caution, this type of research is getting more difficult to do because previously public information (e.g., uncompensated care, workforce staffing levels) is being deemed “confidential” and is no longer being made available to researchers