State of the safety net 2014

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

"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
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
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

"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
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

“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
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.

"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

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.

" 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
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)

“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 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

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

BACKGROUND
Direct Relief USA and the Safety Net
PHOTO: MARGARET MALLOY
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

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PHOTO: ANDREW FLETCHER
34 // THE STATE OF THE SAFETY NET 2014 // LEARN MORE DirectRelief.org/USA

State of the safety net 2014

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State of the safety net 2014