Editor’s Note: Counts for FQHC delivery sites in 2013 were updated to reflect the total number of permanent, seasonal, and administrative/service delivery sites in operation.
In 2014, the Affordable Care Act’s (ACA) major coverage expansions—the individual health insurance marketplace and Medicaid expansion—significantly altered the health care landscape. In Michigan, more than 340,000 Michigan residents selected a marketplace plan by March 2015, and as of August 2015, approximately 606,000 Michigan residents had enrolled in the Healthy Michigan Plan, Michigan’s Medicaid expansion program.1,2 As a result of the ACA’s coverage expansions, Michigan’s uninsured rate decreased from 11 percent in 2013 to approximately 8 percent in 2014.3,4These changes have had a major impact on safety net providers across the state.
This brief looks at trends between 2008 and 2014 with regard to Michigan federally qualified health centers (FQHCs) and free clinics.
Key Findings
- Between 2013 and 2014, Michigan experienced a significant growth in the number of FQHC delivery sites, from 164 to 220. During this time, the number of free clinics in Michigan decreased from 73 to 71.
- Between 2013 and 2014, the number of total patients who received care at Michigan FQHCs increased by 7 percent to approximately 600,000 patients.
- The number of patients seeking mental health services increased by 67 percent since 2008, stabilizing between 2013 and 2014. In 2014, nearly 26,000 patients were served.
- Between 2013 and 2014, the number of Medicaid patients served by FQHCs increased by 24 percent, from 250,000 to more than 308,000 patients; and, the number of privately insured patients increased by 28 percent, from 78,000 to nearly 100,000 patients.
- In 2014, approximately 125,000 FQHC patients in Michigan (21 percent) were uninsured, a 28 percent decline from 2013.
- In response to the ACA’s coverage expansions, some free clinics are changing their structure or service scope, including converting to an FQHC or adopting new policies to serve underinsured or Medicaid patients while continuing to see uninsured patients.
Changes in Capacity
Growth in Federally Qualified Health Centers in Michigan
Federally qualified health centers (FQHCs) are defined as organizations that receive federal funding, under Section 330 of the Public Health Service Act, to provide comprehensive primary care services to uninsured and underserved populations. In an effort to expand access to care and increase provider capacity, Affordable Care Act (ACA) funds were appropriated between fiscal years (FY) 2010 and 2014 to expand access to care, including funding for FQHCs. In FY2014, community health center organizations in Michigan received approximately $80.8 million, or 43.9 percent of the total ACA grant funding awarded to the state in that year.5
Between 2013 and 2014, Michigan experienced significant growth in the number of FQHC delivery sites, from 164 to 220 sites.6 Twenty-seven of Michigan’s 83 counties experienced an increase of one or more sites. Of those, seven counties had previously had no FQHC sites. Muskegon County experienced the largest growth (eight new clinics), followed by Macomb (five new clinics), Ingham (four new clinics), and Houghton (four new clinics). By 2014, 55 of Michigan’s 83 counties had at least one FQHC delivery site. FIGURE 1
Figure 1: Change in Number of FQHC Service Delivery Sites, Michigan Counties, 2013–2014
Key: Numbers in each county represent the FQHC service delivery sites operating in 2014. Colors represent the change in number of FQHC sites (2013-2014).
Growth in Number of FQHC Patients
Between 2013 and 2014, the number of total patients who received care at Michigan FQHCs increased by 7 percent to approximately 600,000 patients. The largest growth was seen in patients seeking medical care, which increased by 8 percent, or 32,000 additional patients. Between 2008 and 2014, the number of FQHC patients increased by 67 percent for mental health services, 37 percent for dental services, and 22 percent for medical services. The number of patients seen for substance use services varied year-to-year, which may be due to the relatively few FQHCs that provide substance use services as well as inconsistent FQHC reporting for these services. FIGURE 2
Nationally, there were several contributing factors in the recent shift in mental health services, particularly in the public sector. Between 2000 and 2013, the number of FQHCs offering mental health services grew by 81 percent, as a result of increased funding resources and an increasing demand for such care.7 Additionally, there has been a general increase over the past several decades in patients with mental health disorders seeking treatment.8 These factors may have contributed to the increasing rates seen in the FQHC population.
Figure 2: Number of FQHC Patients, by Service Type, Michigan, 2008–2014
| Service Type | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 |
|---|---|---|---|---|---|---|---|
| Total Unique Patient Count | 469,457 | 514,987 | 537,847 | 546,245 | 570,009 | 558,059 | 595,684 |
| Medical | 376,153 | 413,965 | 433,564 | 432,986 | 441,401 | 426,552 | 458,695 |
| Dental | 130,503 | 148,206 | 158,969 | 175,885 | 185,229 | 176,388 | 178,812 |
| Mental Health | 15,402 | 16,356 | 19,094 | 26,382 | 28,397 | 25,454 | 25,684 |
| Substance Use | 2,811 | 1,478 | 1,095 | 1,953 | 2,253 | 1,451 | 1,249 |
Growth in FQHC Providers
Between 2013 and 2014, FQHCs in Michigan increased the number of full time equivalent (FTE) staff across all provider types. In particular, medical providers increased by 18 percent (to 871.8 FTEs), substance use providers increased by 17 percent (to 21.9 FTEs), mental health providers increased by 12 percent (to 135.0 FTEs), and dental providers increased by 5 percent (to 202.8 FTEs). FIGURE 3
Figure 3: FQHC FTEs, by Provider Type, Michigan, 2008–2014
| Provider Type | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 |
|---|---|---|---|---|---|---|---|
| Medical | 609.7 | 682.2 | 688.6 | 725.6 | 755.1 | 738.1 | 871.8 |
| Dental | 132.7 | 158.8 | 167.7 | 186.3 | 189.5 | 194.0 | 202.8 |
| Mental Health | 44.0 | 54.2 | 66.2 | 79.7 | 119.2 | 120.2 | 135.0 |
| Substance Use | 7.7 | 7.3 | 8.3 | 10.0 | 17.4 | 18.7 | 21.9 |
| Total FTEs | 794.1 | 902.5 | 930.8 | 1,001.5 | 1,081.2 | 1,070.9 | 1,231.5 |
Changes in Coverage among FQHC Patients
Between 2013 and 2014, Michigan FQHCs experienced a substantial shift in the volume of Medicaid, privately insured, and uninsured patients. The number of Medicaid patients seen at FQHCs increased by 24 percent from 250,000 to more than 308,000 patients (representing more than half of all patients served in 2014). The number of privately insured patients increased by 28 percent, from 78,000 in 2013 to nearly 100,000 patients in 2014. In 2014, approximately 125,000 FQHC patients in Michigan (21 percent) were uninsured, a 28 percent decline from 2013. This was the lowest number and percentage of uninsured patients over the seven-year period. FIGURE 4
Figure 4: Number and Proportion of FQHC Patients, by Coverage Type, Michigan, 2008–2014
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | |
| Medicaid | 188,352 | 40.1% | 210,891 | 41.0% | 225,356 | 41.9% | 240,545 | 44.0% | 258,694 | 45.4% | 249,279 | 44.7% | 308,303 | 51.8% |
| Uninsured | 151,613 | 32.3% | 172,728 | 33.5% | 184,890 | 34.4% | 178,903 | 32.8% | 181,448 | 31.8% | 175,008 | 31.4% | 125,195 | 21.0% |
| Private | 80,813 | 17.2% | 77,857 | 15.1% | 75,786 | 14.1% | 76,473 | 14.0% | 76,461 | 13.4% | 77,837 | 13.9% | 99,312 | 16.7% |
| Medicare | 43,199 | 9.2% | 45,691 | 8.9% | 49,134 | 9.1% | 48,765 | 8.9% | 52,227 | 9.2% | 54,512 | 9.8% | 62,533 | 10.5% |
| Other Public | 5,480 | 1.2% | 7,820 | 1.5% | 2,681 | 0.5% | 1,559 | 0.3% | 1,179 | 0.2% | 1,423 | 0.3% | 341 | 0.1% |
| Total | 469,457 | 100.0% | 514,987 | 100.0% | 537,847 | 100.0% | 546,245 | 100.0% | 570,009 | 100.0% | 558,059 | 100.1% | 595,684 | 100.0% |
Changes to Number and Structure of Free Clinics in Michigan
Free clinics are nonprofit organizations that provide medical, dental, pharmaceutical, mental health, and other services to uninsured individuals by licensed volunteer providers for little or no cost. Between 2013 and 2014, Michigan free clinics declined from 73 to 71.9 Only one new clinic opened during this time. More than half of Michigan’s 83 counties (47) had no free clinics in 2014. FIGURE 5
As a result of the ACA’s coverage expansions, many patients who previously sought care at free clinics became eligible for Medicaid or private insurance, which has generally lowered patient census at free clinics. In response, some clinics have adapted to meet the needs of their community, including converting to an FQHC, adopting new policies to serve underinsured patients or accepting Medicaid patients while continuing to see uninsured patients.10 Some clinics are offering more case management services to fill remaining gaps in the community, such as educating patients on enrollment options or offering educational sessions on nutrition, fitness, or diabetes management. Others have chosen to reduce hours or close in response to the decline in patient volume, particularly in rural regions of the state. Despite these changes, most free clinics in Michigan continue to provide care for uninsured patients in their communities.11
Figure 5: Number of Clinics in Michigan, 2014
Key: Numbers in each county represent the free clinics operating in 2014.
Conclusion
Methodology
FQHC and Free Clinic Data
Federally qualified health center data were obtained from the Health Resources and Services Administration (HRSA).12 The number of patients and providers was collected for medical, dental, mental health, and substance use services. Medical staff included: physicians, nurses, nurse practitioners, physician assistants, and certified nurse midwives, while dental staff included dentists and dental hygienists. Both mental health and substance use providers were already categorized by HRSA into respective groups. Counts of delivery sites were from the Michigan Primary Care Association directories and cross-referenced with the list of FQHCs and Look-Alikes listed in the HRSA delivery sites directory.
Free clinic data were obtained by collected historical data from Free Clinics of Michigan (FCOM) as well as current listings of free clinics on the FCOM website. Blue Cross Blue Shield of Michigan also provided historical data for their free clinic grantees between 2010 and 2014.
Suggested Citation: Peters, Claire, Fangmeier, Josh, and Udow-Phillips, Marianne. Safety Net Providers in Michigan: 2014. September 2015. Center for Healthcare Research & Transformation. Ann Arbor, MI.