Nonprofit community health centers and clinics that provide preventive and primary healthcare services for 24 million people – or one in 13 persons in the U.S. – report that the first year of the Affordable Care Act’s implementation had uneven effects, particularly between facilities in Medicaid expansion and non-expansion states.

The findings were released today by Direct Relief in The State of the Safety Net 2014, an annual report that examines issues and trends within the extensive network of nonprofit, community-based health centers and clinics, which are the principal point of access to healthcare and the medical home for persons with low incomes, without health insurance, and among the country’s most vulnerable.  Such facilities include Federally Qualified Health Centers (FQHCs), nonprofit community-based health clinics, and free and charitable clinics.

Nonprofit safety net health centers and clinics are licensed in different states that have differing reporting requirements, which presents a challenge for analysis of facility-level data across all states.  FQHCs are a notable exception, because each is required annually to submit information to the federal government in addition to that required by the state in which it operates.

Drawing insights from both the most recent FQHC data and nationwide surveys of safety net providers – this year’s report reveals four recurring threads pertaining to the ACA’s initial and anticipated impact on the nonprofit health centers and community clinics that comprise, in large part, the nation’s health safety net:

The need for charitable health care remains. There will continue to be gaps in coverage for immigrants (documented and undocumented) and those who will otherwise fall through the cracks. Under any immediate scenario, states that have chosen not to expand Medicaid will continue to have higher levels of people who are uninsured than in the expansion states.

“The undocumented won’t quality for the exchanges, and they won’t even qualify for Medicaid, so I still think that our 25 percent uninsured rate will stay relatively constant, at least until some of the immigration debates are ultimately decided among Congress,” said Sean Granahan, President and general counsel of The Floating Hospital in Long Island City, N.Y.

Insurance alone does not guarantee access to high-quality care. Unease exists throughout the safety net over its ability to meet the demand for services among the newly insured, which dramatically outpaces the supply of health facilities and health professionals.

“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,” said Judy Jones, Executive Director, Bethel Free Health Clinic, Inc., Biloxi, Miss.

Geography matters. Geographic unevenness is amplified by the unevenness of the insurance exchanges (federal and state), in the varying public health and economic conditions across the country, and even in the differential risk of natural disasters in places where the law’s outcomes are as yet unknown.

“We know a little over 90,000 people in Oklahoma County are uninsured and have a household income at 200 percent Federal Poverty Level,” said Pam Cross Cupit, Executive Director, Health Alliance for the Uninsured,Oklahoma City, Okla.  “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.  Unfortunately, whereas we thought things might be improving for our population, it’s not going to improve very much.”

“I think the ACA will help people have access to specialists that previously they did not have access to,” said Barb Tylenda, Executive Director, Health Care Network, Racine, Wis.

Momentous changes yet to come. The shifting landscape of insurance coverage and health providers that treat low income patients is creating a more complex health care safety net.

“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,” said Dan Ahearn, CEO, Community Health Alliance, Reno, Nev.

The full State of the Safety Net 2014 report is available here: https://www.directrelief.org/2014/11/state-safety-net-2014-2/