Federally Qualified Health Centers and Care for Vulnerable Populations

《患者保护和平价医疗法案》（ACA）大幅增加了联邦对联邦医疗服务的资助。 合格的卫生中心（CDHCs），从2011年到2015年提供110亿美元，以扩大现有的CDHCs， 建立新的健康中心。这笔资金的目标是加强初级保健的供应， 领域，以满足与ACA保险覆盖范围相关的护理需求的预期增长 特别是在低收入的美国人中。数百万低收入美国人获得了保险 从2014年开始，由于医疗补助的扩大和为市场提供低收入补贴， 覆盖然而，迄今为止，几乎没有证据表明， 改善他们所服务的社区的护理或成果。我们将研究 联邦卫生保健基金在三组结果方面的变化：1）门诊护理，包括初级和 专科护理访问，护理来源（例如，预防性保健与非预防性保健）和哨点预防性保健质量 措施; 2）下游临床事件，包括急诊科就诊（急诊和非急诊） 急诊）、住院（总体和门诊护理敏感性疾病）和死亡率;以及 3)总支出和部分支出（例如，门诊病人、住院病人、药房）。我们将专注于体验 医疗补助受益人，因为他们是政策的中心焦点，因为我们能够检查 全面的、企业级的索赔数据，包括一段时间内的利用率、诊断和支出，以及 对这一人群的关怀。我们将使用具有剂量反应的交错实施设计 比较受益人结果变化的模式（剂量由供资数额决定） 居住在人均联邦公共卫生资金增加较大和较小的地区。是因为资金 水平可能与基线能力或质量的粮农组织，我们将使用一个固定的影响 一种估计方法，用于解释个体、CNOHC之间不可测量的时不变差异， 地方。我们还将调整一系列随时间变化的协变量，以反映 个体-（例如，合并症）或区域水平的护理需求（例如，保险范围组合），以及地区- 使用链接数据集的级别提供者供应（例如，美国社区调查）。我们将分别检查 经验：1）受益人谁是连续合格的医疗补助（明确需要），之前 以及资金增加后（2007-2017年）; 2）2014年新符合医疗补助资格的受益人（成人 2014-2017年期间，收入<138% FPL），在此期间， 经费ACA的社区卫生中心基金在2016-2017年延长了72亿美元;然而， 2017年后的资金来源不确定。这项研究将提供关于CO2-HC变化影响的第一批信息 在覆盖面不断扩大的动态时期提供资金，为决策者提供可采取行动的证据 寻求切实有效的办法，改善弱势群体获得护理的机会和结果。

The Patient Protection and Affordable Care Act (ACA) substantially increased federal funding for federally qualified health centers (FQHCs), providing $11 billion from 2011 to 2015 to expand existing FQHCs and establish new health centers. The goal of this funding was to bolster the supply of primary care in underserved areas to meet some of the anticipated increases in demand for care associated with ACA insurance coverage expansion, particularly among lower-income Americans. Millions of lower-income Americans gained coverage starting in 2014 due to Medicaid expansion and the provision of low-income subsidies for marketplace coverage. To date, however, there is little evidence on whether funding increases for FQHCs are associated with improvements in care or outcomes for the communities they serve. We will examine the effects of changes in federal FQHC funding on three sets of outcomes: 1) outpatient care, including primary and specialty care visits, sources of care (e.g., FQHC vs. non-FQHC), and sentinel preventive care quality measures; 2) downstream clinical events, including emergency department visits (for emergent and non- emergent conditions), hospitalizations (overall and for ambulatory care sensitive conditions), and mortality; and 3) total and component spending (e.g., outpatient, inpatient, pharmacy). We will focus on the experience on Medicaid beneficiaries because they were a central focus of the policy and because we are able to examine comprehensive, beneficiary-level claims data on utilization, diagnoses, and spending over time, and across sites of care for this population. We will use a staggered implementation design with a dose-response model (where dose is determined by the amount of funding) to compare changes in outcomes for beneficiaries living in areas that received larger vs. smaller increases in per capita federal FQHC funding. Because funding levels could be associated with the baseline capacity or quality of the FQHCs, we will use a fixed effects estimation approach to account for unmeasured time-invariant differences across individuals, FQHCs, and local areas. We will also adjust for a range of time-changing covariates to reflect potential changes in individual- (e.g., comorbidities) or area-level demand for care (e.g., insurance coverage mix), as well as area- level provider supply using linked datasets (e.g., American Community Survey). We will examine separately the experiences of: 1) beneficiaries who were continuously eligible for Medicaid (categorically needy), before and after the funding increases (2007-2017); and 2) beneficiaries newly eligible for Medicaid in 2014 (adults with incomes <138% FPL) over the period 2014-2017, during which time there is ongoing variation in FQHC funding. The ACA's Community Health Center Fund was extended in 2016-2017 at $7.2 billion; however, funding after 2017 is uncertain. This study will provide the first information on the effects of changes in FQHC funding during a dynamic period of coverage expansion to provide actionable evidence for policymakers seeking effective and efficient approaches for improving care access and outcomes for vulnerable populations.