2012 State of the Safety Net

MISSION OF MERCY CLINIC

THE STATE of THE
SAFETY NET 2012
 man receives care at
A
Mission of Mercy Clinic in The Economic Crisis and America’s
Nonprofit Clinics and Health Centers
Brunswick, Maryland—
one of 8,000 nonprofit,
community-based health
facilities collectively serving
21 million people annually
in the U.S.

THE STATE OF THE SAFETY NET 2012 // CONTENTS DirectRelief.org/USA // 2

/// ONTENTS
C
4 //
INTRODUCTION
Economic Crisis and the
U.S. Healthcare Safety Net
8 //
THE PROVIDERS
Direct Relief’s 2012 Nationwide
Partner Outlook Survey
12 //
THE PATIENTS
People Being Cared for
by the Safety Net
16 //
THE CONDITIONS
Chronic Illness and Insurance Status 8,000 HEALTH FACILITIES,
20 //
THE COMMUNITIES 50 STATES,
26 //
BACKGROUND
21 MILLION PATIENTS
1/3 LACK INSURANCE,
Direct Relief USA and
the Safety Net


WILLIAM VAZQUEZ FOR ABBOTT FUND
28//
METHODOLOGIES
30//
71% BELOW POVERTY LEVEL
LEARN MORE
Venice Family Clinic, Venice, California


“State cuts and the current
economic situation have
increased the need for our
services. We are trying our best
to do more with less.”
—RYAN MESSINGER, ASSISTANT DIRECTOR,
HEALTHNET OF ROCK COUNTY, INC.,
JANESVILLE, WISCONSIN


THE STATE OF THE SAFETY NET 2012 // INTRODUCTION DirectRelief.org/USA // 4

If these facilities did
T his report summarizes the results
of the largest national survey
conducted in 2012 of U.S. nonprofit
community-based health clinics, Federally
not exist, they would Qualified Health Centers (FQHCs), and
free clinics as well as the most current
have to be invented. available national data (from 2006-2010)
about patients and activities at America’s
FQHCs.
The conditions, perceptions, and
trends recorded at these nonprofit,
community-based healthcare facilities
about how they and their patients are
faring in 2012 reflects what a broad
and diverse cross-section of healthcare
providers believes to be the state of the
nonprofit healthcare safety net in the U.S.

THIS IS WHAT A BROAD
CROSS-SECTION OF PROVIDERS
BELIEVES TO BE THE STATE OF
NONPROFIT HEALTH CARE.
Clínica Monseñor Oscar A. Romero,

Los Angeles, California This is a snapshot of the efforts
by a wide array of America’s nonprofit
healthcare institutions to serve the most

///NTRODUCTION
I
vulnerable people during an ongoing
period of intense economic stress. This
report takes no position on the causes

of the recession. Instead, it illuminates
some of the many ways in which people

Economic Crisis and the U.S. throughout the U.S. — particularly those
with low incomes and without health
insurance — depend daily upon the safety

Healthcare Safety Net net, including during emergencies.
The private, nonprofit community-
based health facilities that are the subject
of this report operate independently.

THE STATE OF THE SAFETY NET 2012 // INTRODUCTION Direct Relief USA // 5


Los Angeles, California UNDER ANY SCENARIO
QUESTIONS REMAIN ABOUT HEALTHCARE REFORM
IMPLEMENTATION, BUT THE CRITICAL ROLE OF AMERICA’S
NONPROFIT HEALTH CENTERS AND CLINICS REMAINS CLEAR.

As this report was finalized, the U.S. Supreme Court issued its highly
anticipated decision on The Patient Protection and Affordable Care
Act, which was enacted into law in 2010. The Court upheld the
constitutionality of the so-called “individual mandate” relating to
the purchase of private health insurance. However, the ruling also
CLÍNICA MONSEÑOR OSCAR A. ROMERO

permitted states to opt out of the expanded Medicaid provisions in the
law, which were expected to cover 17 million people.
The Court’s decision allows attention to be focused on how
the law will be implemented and its ultimate effects, about which
significant uncertainty unavoidably remains. However, the nonprofit
safety-net facilities that are the subject of this report are certain to
continue to play a critical role in providing access to comprehensive
health care for people with low incomes, regardless of their
INTRODUCTION insurance status. These facilities existed before the law was enacted,
are deeply embedded within thousands of communities across the
Direct Relief estimates they run over role extends to emergency situations, U.S., and are providing access and services to millions of people.
8,000 healthcare sites in all 50 states and during which the low-income persons Moreover, these facilities specialize in and have achieved
provide comprehensive health care and whom the facilities disproportionately demonstrable success on many of the issues about which broad
referral services to over 21 million people, serve are among the most vulnerable. consensus exists — expanded access to affordable, high-quality
approximately 37.5 percent of whom lack There are also other facilities, particularly services and increased emphasis on preventive and primary care.
health insurance and 71.8 percent have hospital emergency rooms, and a wide If these facilities did not exist, they would have to be invented to
incomes at or below the Federal Poverty array of programs run by government and accomplish these goals. The examination of their circumstances
Level (FPL— $23,050 per year for a family other nonprofit and religious institutions and trends reflects how the healthcare needs of people in the United
of four). that provide essential health and social States, particularly those with low incomes, are being met. It will also
Because these facilities and their services in the country. be a way to gauge progress against the broader consensus policy goals
staffs provide care regardless of a person’s This report also contains two case of access to affordable, high-quality health care services for all people.
insurance status, income, or ability to pay, studies that highlight why the term
they are a large, essential component of “safety net” is apt in describing these
the healthcare safety net in the U.S. for facilities’ roles on a daily basis and during
people who otherwise have limited options emergencies. The first looks at Detroit,
to access care they need. This safety-net Michigan, a community hard hit by the


The U.S. has 5,750
hospitals and more than
8,000 nonprofit clinics.

FAMILY CARE HEALTH CENTERS
Barry Wilson, Chief Pharmacy

Officer of Family Care Health
Centers in St. Louis, Missouri,
restocks pharmacy shelves.

INTRODUCTION
THESE FACILITIES ARE recession, where clinics have seen a 10 facilities generates significant, unique data through a nationwide network of locally
A LARGE, ESSENTIAL percent rise in patient volume since 2008. on a national scale and a perspective that run, community-based nonprofit health
The other examines the case of Joplin, is otherwise unavailable. centers and clinics — on an ongoing basis
COMPONENT OF THE
Missouri, where nonprofit clinics and health Direct Relief USA is the only and during emergencies. Direct Relief
HEALTHCARE SAFETY NET IN
centers helped care for thousands of people U.S. nonprofit licensed to distribute identifies gaps and provides donations
THE U.S. FOR PEOPLE WHO
when the main hospital was destroyed by a prescription medications in all 50 states. It of medications and health supplies for
OTHERWISE HAVE LIMITED
devastating tornado. is a private charitable effort to help people clinic and health-center patients with low
OPTIONS TO ACCESS CARE Direct Relief’s extensive day-to-day who lack financial means obtain access incomes and no or inadequate insurance.
THEY NEED. interaction with America’s safety-net to the care and medications they need


TERMINOLOGY //
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 1,000 community clinics, Federally
Qualified Health Centers, or free and 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.

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 8,000 clinical sites
providing comprehensive, culturally-competent health services to more than 21 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 were 1,124 FQHCs operating almost 7,000 sites in 2010
that treated 19.5 million people across the United States, of whom 7.3 million lacked health
insurance.

Free Clinic – a nonprofit, typically volunteer-based provider facility that treats anyone

regardless of ability to pay, that typically treats patients free of charge, or with a nominal
donation for services. An estimated 1,000 free clinics operate across the United States.

Look-Alike – an organization that meets the eligibility requirements of the 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 Venice Family Clinic, Venice, California

reimbursement, and eligibility to purchase prescription and non-prescription medications at a
reduced rate, among other benefits.

THE STATE OF THE SAFETY NET 2012 // THE PROVIDERS Direct Relief USA // 8

“ e are seeing much sicker and more complex patients.
W
As a result, the level of care provided in this clinic has
changed. The community health centers are becoming
maxed out with uninsured patients.”
—JANICE ERTL, CLINIC DIRECTOR, ST. VINCENT DE PAUL CLINIC, PHOENIX, ARIZONA


Los Angeles, California

/// HE PROVIDERS
T
Direct Relief’s 2012 Nationwide

CLÍNICA MONSEÑOR OSCAR A. ROMERO
Partner Outlook Survey

THE STATE OF THE SAFETY NET 2012 // THE PROVIDERS DirectRelief.org/USA // 9

A ssessing current conditions and
trends across America’s nonprofit
safety-net clinics and health centers
prospects for the remainder of 2012. The
survey was distributed to 1,092 clinic and
health center partners in all 50 states.
for health services among patients unable
to pay. Because nonprofit facilities’ own
financial constraints can result in reduced
presents significant challenges. These Direct Relief received 546 responses (50 hours, staffing, and overall capacity to see
PARTNER OUTLOOK SURVEY
15%
facilities operate independently within their percent response rate) from clinics in 49 patients, the survey also inquired about
T THE SAME
communities and have different reporting states and Washington D.C. facilities’ staffing levels and operating hours
requirements. Even where one can collect Overall, the survey results reflected
1,092 Clinics Health Centers to gauge the relation between capacity in
standard information, at the more than continued pressure in providing services 546 Responses the safety net and demands upon it.
1,000 Federally Qualified Health Centers and concern among nonprofit providers Overall, the survey found that facilities
6% (and FQHC Look-Alikes) nationwide, such about their ability to care for an increasing
49 States + D.C. had expanded capacity as measured
REASE information is reported on an annual basis number of patients in an increasingly by increased staffing (56 percent) and,
that enables only retrospective analysis challenging environment. Seventy-nine to a lesser degree, by operating hours
after it is made available the following year. percent of respondents indicated that they percent of respondents indicated their (41 percent), although the adequacy of
As economic struggles continued saw more patients in 2011, and 86 percent belief that the environment would be more such increases against demand was not
into early 2012, Direct Relief surveyed its expected an increase in the number of challenging. examined. In contrast, among the facilities
nationwide partner network of nonprofit patients without health insurance during In a commercial enterprise, a spike that reported a decrease in staffing (16
safety-net community clinics and health 2012. When asked about their overall in demand would be expected to generate percent) a majority indicated that it was
centers about their current circumstances, outlook for the remainder of 2012 with either higher prices or expanded supply (or due to a decrease in funding.
trends, and perceptions about near-term respect to funding and patient trends, 83 both). Neither occurs when the demand is The following charts show the
responses to the survey.

DID YOUR FACILITY SEE AN INCREASE, DECREASE,
OR NO CHANGE IN THE TOTAL NUMBER OF PATIENTS IN 2011?

79% 15%
INCREASE ABOUT “ any of our formerly insured patients now have little
M
THE SAME
or no health coverage. This means more demand
and fewer services available. As these patients will
not receive day-to-day well-care, there will be a
corresponding increase in primary health care needs.
This is taxing community clinics in California.”
— SUSAN EDMONDSON, PHARMACY PROGRAM MANAGER, LIFELONG MEDICAL
6% CARE, BERKELEY, CALIFORNIA
DECREASE


DID YOUR FACILITY EXPERIENCE AN INCREASE, DECREASE,
OR NO CHANGE IN THE HOURS OF OPERATION?

56% 41%
ABOUT THE SAME INCREASE

“ e are totally funded by grants and donations. These
W
3% DECREASE sources are becoming more difficult to find and obtain
and we are really struggling to keep the doors open.”
— LINDA TAYLOR, CLINICAL MANAGER, COWLITZ FREE MEDICAL CLINIC,
3% DECREASE LONGVIEW, WASHINGTON

50% 33.3%
FEWER PATIENTS DECREASE IN 16.7%
IN NEED OF SERVICE FUNDING OTHER

IF YOU EXPERIENCED A DECREASE IN HOURS OF
OPERATION, WHY WAS THAT THE CASE?

DID YOUR FACILITY EXPERIENCE AN INCREASE, DECREASE,
OR NO CHANGE IN OVERALL STAFFING LEVELS?

56% 28% “ e continue to experience an increase in uninsured
W
INCREASE NO CHANGE
patients — several large companies have closed here.
We also reduced staff due to cuts in state funding.”
— MARY DAVIS, DIRECTOR OF NURSING, COMMUNITY HEALTH SERVICE AGENCY,
GREENVILLE, TEXAS

16% DECREASE
IF YOU EXPERIENCED A DECREASE
IN STAFF, WHY WAS THAT THE CASE?

50% 18.8%
DECREASE 31.3% DECREASE
IN FUNDING OTHER IN DEMAND


IN 2012, DO YOU EXPECT THAT THE NUMBER OF PATIENTS
WITHOUT HEALTH INSURANCE WILL INCREASE, DECREASE,
OR STAY THE SAME?

86% 12%
INCREASE STAY
THE
SAME
“ e are seeing more uninsured and it’s really taking a
W
toll on our funding from any source. We are not sure
how we are going to be able to balance things and keep
up with the demand from the uninsured.”
— TRACEY CAUSEY, CEO, VERNON J. HARRIS EAST END COMMUNITY HEALTH
CENTER, RICHMOND, VIRGINIA
2%
DECREASE

BASED ON FUNDING AND PATIENT TRENDS, DO YOU THINK
2012 WILL BE EASIER, MORE CHALLENGING, OR ABOUT THE
SAME COMPARED WITH 2011?
“ ue to continued lay-offs, we expect to see a great
D
increase in our patients. Our donations have also taken
83% 13%
MORE CHALLENGING ABOUT a large drop. People who in the past have been donors
THE SAME
are now likely to become patients.”
— DEBBIE LEAKEY, LPN, GOOD SAMARITAN CLINIC, FORT SMITH, ARKANSAS

4%
EASIER

THE STATE OF THE SAFETY NET 2012 // THE PATIENTS DirectRelief.org/USA // 12

 John Hoh, Medical Director
Dr.
of Asian Pacific Health Care
Ventures in Los Angeles,
California, examines a patient.

/// HE PATIENTS
T
People Being Cared for
by the Safety Net
Most patients live at
or below the federal
poverty level.
MARGARET MOLLOY


T he following provides an overview of patient information from 2010 for
the nearly 20 million people treated annually at the nation’s Federally
Qualified Health Centers (FQHCs) and Look-Alikes.
KNOWN INCOME LEVEL OF FQHC PATIENTS // 2010
Total patients = 14.9 million

 19.5 million total patients served 71.8% 14.4%
AT OR BELOW 100% OF 101-150%
 7.3 million patients (37.5%) lacked health insurance
FEDERAL POVERTY LEVEL (FPL) OF FPL

 he vast majority (71.8%) of patients with known
T
income levels live at 100% or below the federal
poverty level (FPL) — in 2010, that was $10,830 for an 7.2% 6.5%
OVER 151-
individual and $22,050 for a family of four. 200% 200%
OF FPL OF FPL
 131,660 total staff (full time equivalents)
The following charts show demographic information on patients at FQHCs in
2010, and what has changed compared to previous years.

15

TOTAL PATIENTS IN MILLIONS
TOTAL FQHC PATIENTS,
KNOWN INCOME LEVELS //
2006-2010
12
From 2006-2010, the
number of patients seen at
FQHCs increased by 29.5%.
9
In the same period, the
percentage of patients with
incomes below 100% of the 70.7% 70.4% 69.9% 71.4% 71.8%
AT OR BELOW
federal poverty level (FPL) 6 100% OF FPL
dipped slightly from 2006-
101-150%
2008 (70.7%  69.9%) and OF FPL

increased from 2008-2010 3
151-200%
(69.9%  71.8%). OF FPL

OVER 200%
OF FPL
0
2006 2007 2008 2009 2010


INSURANCE SOURCE OF FQHC PATIENTS // 2010 TOTAL PATIENTS, INSURANCE SOURCE // 2006-2010
Total patients = 19.5 million FQHC patients’ sources of insurance shifted slightly from 2006-2010, but
2010 was the first year that Medicaid patients exceeded uninsured patients
38.5% 37.5% in total numbers and as a percentage of the overall patient population.
MEDICAID UNINSURED
20

PATIENTS IN MILLIONS
15
37.5%
13.9% 7.5% 38.2%
PRIVATE MEDICARE
38.3%
38.9%
39.8% 38.5%
10 37.1%
35.8%
2.5% PUBLIC 35.1%
35.4%
NONE/UNINSURED

MEDICAID
5
PRIVATE INSURANCE

MEDICARE

PUBLIC INSURANCE
0
2006 2007 2008 2009 2010

“W
e are seeing people who are sicker than ever and do not know what to do about it. They are
new to the system. They have lost their job, their insurance, their home, their car, and filed for
bankruptcy. They have never been in this shape before.”
— TRACY THOMPSON, EXECUTIVE DIRECTOR, MERCY HEALTH CENTER, ATHENS, GEORGIA


A 2010 SNAPSHOT OF GENDER, RACE, AGE/GENDER OF FQHC PATIENTS // 2010
AND ETHNICITY AT FQHCs FEMALE = 11.45 MILLION PATIENTS MALE = 8.02 MILLION PATIENTS
85+
 There were almost twice as many women
80-84

seen between the ages of 25-44 than men 75-79

70-74
(3.4 million versus 1.9 million).
65-69
FEMALE = 11.45 MILLION PATIENTS 85+ MALE = 8.02 MILLION PATIENTS

AGE OF PATIENTS
 Those aged 50-69 are the fastest growing
80-84
60-64

55-59
group as a proportion of the whole, yet 75-79
50-54
70-74
children are still the largest overall 45-49
65-69
proportion. 40-44

AGE OF PATIENTS
60-64
35-39
55-59
 The FQHC population is 35% Hispanic/
30-34
50-54
Latino while, according to the 2010 U.S. 25-29
45-49 20-24
Census, nationally only 16% of the U.S. 40-44 15-19
population is Hispanic/Latino. 35-39 10-14
30-34 5-9

25-29 0-4

20-24 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

15-19
NUMBER OF PATIENTS = 19.47 MILLION
10-14

5-9

0-4

RACE OF FQHC PATIENTS // 2010 1,200,000 1,000,000 800,000 600,000 400,000 200,000 ETHNICITY // 2010
0 200,000 400,000 600,000 800,000 1,000,000 1,200,000

NUMBER OF PATIENTS = 19.47 MILLION

65% 35% 16%
64.1% 25.8% 84%
WHITE BLACK HISPANIC/LATINO

NOT HISPANIC/LATINO

1.4%
AMERICAN 65% 35% 16%
INDIAN/ 84% PATIENTS
FQHC NATIONAL POPULATION
(U.S. Census Bureau, 2010)
ALASKA
NATIVE

1.3%
HAWAIIAN/
PACIFIC
ISLANDER FQHC PATIENTS NATIONAL POPULATION
4.2% 3.3% (U.S. Census Bureau, 2010)
MORE THAN ONE RACE ASIAN

THE STATE OF THE SAFETY NET 2012 // THE CONDITIONS DirectRelief.org/USA // 16

M
ore people with
chronic conditions
are being cared for
at nonprofit health
facilities.

/// HE CONDITIONS
T
Chronic Illness and Insurance Status
South Central Family


MARGARET MOLLOY
Health Center, Los Angeles,
California


12% OF ALL FQHC VISITS ARE FOR SELECTED
CHRONIC DISEASES // 2010
[ 12.28% SELECTED CHRONIC DISEASES ] An analysis of the 2010 data shows the
continuing trend of an increase in the
number of patients with chronic health
88% conditions. This is significant not only
ALL OTHER PRIMARY DIAGNOSES because these conditions result in a large
5.42%
• CHILDHOOD CONDITIONS HYPERTENSION percentage of total services provided
• COMMUNICABLE DISEASES
(two diagnoses, diabetes mellitus and
• DENTAL SERVICES
• DIAGNOSTIC TESTS hypertension, account for 10 percent of all
• MENTAL HEALTH SUBSTANCE ABUSE CONDITIONS 4.81% visits nationwide), but they require more
• NONCOMMUNICABLE DISEASES DIABETES
• PREVENTIVE SERVICES services over a longer period of time,
• SCREENINGS
• OTHER SELECTED DIAGNOSES thereby adding disproportionate stress on
staffing and budgets.
0.84%
HEART DISEASE

1.21%
ASTHMA

Direct Relief analyzed the rate of change in INCREASE IN PATIENTS WITH SELECTED CHRONIC DISEASES AT FQHCs (2006-2010)
chronic diseases facing clinics and health
centers: heart disease, asthma, diabetes, +5.2%
2.0 +10.9%
IN MILLIONS

and hypertension. In an analysis from
2006 to 2010, the rates of these conditions +6.9%
+8.5%
noted in red are increasing at a rate higher
than that of the FQHC patient population 1.5
as a whole. This outpacing creates further +7.8%
+10.7%
resource concerns as health centers are +5.7%
+9.0%
not only treating more patients annually,
1.0
but more patients with chronic conditions.

+9.2% +1.6% HEART DISEASE
+2.2% +5.2%
0.5 ASTHMA
-0.1% +5.8% +6.7% -0.04%
DIABETES

HYPERTENSION
0

2006 2007 2008 2009 2010


DIABETES AMONG FQHCs AND DIRECT RELIEF NETWORK Figure 1
CHANGE IN DIABETES DIAGNOSES AT FQHCs BY STATE // 2007-2010
The rate of patients seen at FQHCs for diabetes as their primary diagnosis has 12%
remained flat nationally at just over six percent since 2007. Several states — USA RATE OF
10% DIABETES DIAGNOSES
including Oregon, Nevada, and Virginia — have seen their rates increase by
VIRGINIA
between one percent and three percent annually during that time (Figures 1 and 8%
2). While rates may be increasing in some states, it is not all negative news. In KANSAS
6%
the case of many states, increased rates of diagnosis and treatment of diabetes INDIANA
DIABETES CHANGE IN % 2007-2010
have been accompanied by improved quality and effectiveness of care, indicated 4% OREGON
by improved control of blood sugar levels (HbA1c — Figure 3). In Virginia, for
2% -1% 0 NEVADA
3%
instance between 2009 and 2010, the only two years for which we have reliable
0 WISCONSIN
data, the number of patients with HbA1c counts exceeding nine (indicating
2007 2008 2009 2010
dangerously high blood sugar) declined by six percent even as their rate of Figure 2
persons diagnosed and treated for diabetes increased from eight percent to 11 STATES WITH THE LARGEST INCREASES AND DECREASES
percent. IN THE RATES OF DIABETES DIAGNOSES AT FQHCs // 2007-2010

USA RATE OF
FINDINGS FROM DIRECT RELIEF SURVEYS 12% DIABETES DIAGNOSES
Critical gaps remain in understanding the changing relationships between VIRGINIA
chronic illness, poverty, and health insurance. Because the best publicly 10%
KANSAS
available data on FQHCs — the Health Resources and Services Administration's
8% WISCONSIN
(HRSA), Uniform Data System (UDS) — does not include cross-tabulated
patient data, Direct Relief has attempted to understand these relationships INDIANA
6%
through routine surveys of its own partner network. In a survey on changes NEVADA

in numbers of patients with diabetes without health insurance between 2009 OREGON
4%
and 2010, Direct Relief received responses from 432 clinics and health centers 2007 2008 2009 2010
in its partner network. Roughly half of the responses were from FQHCs and
Look-Alikes and one-third were from free clinics. While the findings on health
insurance were consistent with the overall FQHC reporting, which indicated Figure 3
little to no change in the proportion of uninsured, there was evidence that CONTROLLING DIABETES: CHANGE IN PATIENTS WITH
patients with diabetes who lacked health insurance were being seen at a HbA1c% 9 AT FQHCs BY STATE //2009-2010
significantly higher rate than increases in people without insurance and in the
patient population as a whole.
Direct Relief’s partners reported seeing a 5.29 percent increase in total
patients and only a 0.76 percent increase in patients without health insurance.
They reported a 6.89 percent increase in patients with diabetes who lacked
health insurance. This finding tends to suggest that the patients without
insurance are more likely than other groups of patients to present with HbA1c% 9 CHANGE IN % 2009-2012

diabetes, which pose financial strains for individuals and clinics alike given the
-24% 0 14%
high costs of chronic medications and long-term healthcare.


INSURANCE MEDICAID TRENDS AT FQHCs
The most salient trend in health insurance at FQHCs from 2007 to 2010 was the rapid the same time though, the rate of persons on Medicaid increased substantially, from
increase in the proportion of patients on Medicaid, above and beyond those reported to 35 percent to 39 percent. In 2010, Medicaid patients exceeded the rate of uninsured
be uninsured. Between 2007 and 2010 the rate of people without insurance being seen patients for the first time since UDS data has been collected. This trend in insurance
at FQHCs actually decreased two percent nationally, from 40 percent to 38 percent. The payments has been consistent annually and not confined to any particular section of the
total patient population did increase, so despite the percentage drop the total number country. Whereas all but five states saw either no change or an increase in their rate of
of people without insurance being seen at FQHCs increased during this time period. At Medicaid patients, a total of 33 states either saw no change or a decrease in their rate of
uninsured patients.

CHANGE IN PATIENTS WITHOUT INSURANCE AT FQHCs BY STATE // 2007-2010 CHANGE IN MEDICAID PATIENTS AT FQHCs BY STATE // 2007-2010

USA RATE OF
60% UNINSURED PATIENTS

NEVADA
50%
DELAWARE
40%
WYOMING
30% WISCONSIN

UNINSURED CHANGE IN % 2007-2010 20%
MEDICAID CHANGE IN % 2007-2010 NORTH DAKOTA

WASHINGTON D.C.
10%
-12% 0 8% -2% 0 13%

2007 2008 2009 2010

STATES WITH THE LARGEST INCREASES AND DECREASES IN THE STATES WITH THE LARGEST INCREASES AND DECREASES IN THE
RATES OF PATIENTS WITHOUT INSURANCE AT FQHCs // 2007-2010 RATES OF MEDICAID PATIENTS AT FQHCs // 2007-2010

USA RATE OF USA RATE OF
60% UNINSURED PATIENTS 60% MEDICAID PATIENTS
NEVADA WISCONSIN
50% 50%
DELAWARE MINNESOTA
40% 40%
WYOMING MAINE
30% WISCONSIN 30%
GEORGIA

20% NORTH DAKOTA 20% OKLAHOMA

WASHINGTON D.C. NEVADA
10% 10%

2007 2008 2009 2010 2007 2008 2009 2010

THE STATE OF THE SAFETY NET 2012 // THE COMMUNITIES DirectRelief.org/USA // 20

/// HE COMMUNITIES
T
Venice Family Clinic, Venice, California


// Expanding Care in a Recession
CASE STUDY // DETROIT, MI
// Role of the Safety Net During Emergencies
CASE STUDY // JOPLIN, MO

Detroit’s unemployment
rate nearly doubled, from

14% to a devastating
rate of nearly 28%.


Community Health and Social

Services, Detroit, Michigan

EXPANDING CARE
IN A RECESSION
CASE STUDY // DETROIT, MI

T he issues faced by people in Detroit,
Michigan have been mounting for
decades. According to the U.S. Census
insurance, particularly given that Detroit
has no public hospital and suffered a steep
decline in health service provision by the
and the Bureau of Labor Statistics, the department of public health since 2008 due
city’s jobs-base shrunk, property values to municipal budget cuts.
plunged, social services were cut back, and In 2010, the most recent year for which
hundreds of thousands of people moved there is reliable data, safety net medical
away. Based on the American Community providers operated a total of 14 clinical
Survey five-year estimate from 2006 to service delivery sites throughout the city
2010, nearly 20 percent of all households of Detroit. Those sites served a patient
in Detroit had annual incomes less than community of 51,672 individuals, up 10
$10,000. These long-term stresses made percent from roughly 46,600 since 2008. The
Detroit more vulnerable than most U.S. safety net patient community has grown
cities to the economic turbulence of 2008. while the population of the city as a whole
From January 2008 to July 2009, Detroit’s has shrunk. Between 2008 and 2010 the
official unemployment rate nearly doubled, proportion of Detroit’s total population being
from 14 percent to a devastating rate of treated at safety net institutions increased
nearly 28 percent. Since then, conditions by one percent overall, from six percent
have improved, but at a pace which to seven percent. Among that patient
DETROIT’S TOTAL POPULATION has failed to restore pre-2008 levels of community in 2010, roughly 61 percent
employment, growth, or funding for social reported incomes at or below 200 percent
BEING TREATED AT SAFETY NET services. of the federal poverty line and 59 percent
INSTITUTIONS INCREASED BY 1% Detroit’s nonprofit healthcare safety reported having no health insurance. At
net — woven from a mix of FQHCs, least 20 percent of patients seen at safety
OVERALL, FROM 6% TO 7%. community clinics, and free clinics — net institutions in Detroit were diagnosed
plays a central role in ensuring availability primarily for hypertension, eight percent for
CHASS

of comprehensive healthcare services diabetes, and three percent for asthma.
for the people who are poor and lack


MARK KIRSCH
Pharmacist, Community Health and Social Services

“ S OF FEBRUARY 2012, THE CITY OF
A
DETROIT HAS CLOSED DOWN THE
HEALTH DEPARTMENT PHARMACY
AND ADULT MEDICAL SERVICES. WE
ANTICIPATE AT LEAST 6,000 NEW
PHARMACY PATIENTS.”
THE STATE OF
DETROIT’S SAFETY NET Pharmacist Mark Kirsch

works in the pharmacy at
Motor City clinic responses Community Health and
Social Services in Detroit,
to Direct Relief’s 2012 Partner Michigan.
Outlook Survey
hree out of four reported an expectation
T
that their overall operating environment
through 2012 would be more challenging;
one reported no expected change.

hree out of four reported an increase in
T
patients; one saw no change in the number
of patients.

wo reported that they expected to see
T
an increase in patients without health
insurance; two expected uninsured rates
would stay about the same.

ne clinic saw an increase in hours of
O
operation; the others reported no change
to their hours.

wo clinics reported an increase in
T
staffing, one saw no change, and one

CHASS
saw a decrease.


DETROIT, MI
CASE STUDY //
Clinics and health centers are located in medically underserved
neighborhoods throughout the country. In Detroit, 14 clinics and health
centers treat more than 50,000 people. Many of these patients live
in communities where nearly a quarter of households earn less than
$10,000 annually.

2010 FAMILIES WITH INCOME LESS THAN
$10,000 (%) BY BLOCK GROUPS

19.11% – 92.86%

12.61% – 19.10%

7.65% – 12.60%

3.79% – 7.64%

0.00% – 3.78%

DETROIT, MI SAFETY-NET CLINICS


DEBRA DAVIDSON  Joplin, Missouri, people
In
gathered in Cunningham

ROLE OF THE
Chief Operations Officer, ACCESS Park, across the street from
Family Care, Joplin MO the damaged St. John’s
Regional Hospital, following
“ CCESS recognized the
A the Joplin Memorial Walk to
commemorate the one-year

SAFETY NET DURING
immediate window of anniversary of the Joplin
Tornado.
opportunity required
to respond…[and]

EMERGENCIES
coordinated efforts with
area health departments
and other medical
CASE STUDY // JOPLIN, MO TORNADO
facilities in the area
providing mass tetanus

L ate in the hot and humid Sunday
afternoon of May 22, 2011, the city of
Joplin, Missouri was struck by a massive
greater need with limited points of care.
Hospitals can be quickly overwhelmed, as
surge capacity is limited, clinics and health
vaccinations in excess of
12,000 persons so far.”
EF5 “supercell” tornado. Wind speeds centers, often working with local public
exceeded 200 miles per hour. Within health departments, serve as an essential
hours, roughly 75 percent of the city was resource.
damaged, 7,000 homes were destroyed,
and 161 persons killed. St. John’s Regional STORM SURVIVORS TURNED TO
Hospital, the area’s primary medical COMMUNITY HEALTH CENTERS
center, was among the many buildings AND CLINICS FOR BOTH ACUTE
crippled by the tragedy. Storm survivors AND CHRONIC MEDICAL CARE IN
turned to community health centers and THE WAKE OF THE DISASTER.
clinics for both acute and chronic medical
care in the wake of the disaster. Located in the heart of tornado
Safety-net clinics are a primary source activity, ACCESS Family Care and the
of healthcare for low-income, uninsured Community Health Clinic of Joplin
families in their communities. Every day, normally treat over 10 percent of Joplin’s
they operate as a crucial component of total population, including much higher
the U.S. health system as they provide proportions of patients who are low-
care for all patients regardless of their income and uninsured. In the hours after

ALIVIA BIRDWELL
ability to pay. Their role becomes even the tornado, ACCESS Family Care set
more critical during times of emergency up temporary care sites and distributed
when resources are strained and there is wound-care supplies, medications, and


 aerial view of the Joplin, MO tornado destruction.
An

U.S. NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION
TORNADO SURVIVORS
TURN TO JOPLIN
CLINICS FOR CARE
PATIENTS SEEN SINCE THE
members involved in debris cleanup.
STORM LAST YEAR CONTINUE
In addition, many people suffered from
TO INCREASE WHILE FUNDING
depression and post-traumatic stress
OPPORTUNITIES DWINDLE
disorder following the disaster. To address
AND GRANTS DECREASE DUE
the mental health needs of uninsured
TO THE ECONOMY.
patients, Direct Relief provided a $32,000
personal care items to an estimated grant to the Community Health Clinic of
15,000 people displaced by the tornado. Joplin. Direct Relief has worked with the
To ensure medical services were not Community Health Clinic of Joplin since
interrupted, Direct Relief bolstered its August 2009 to provide donations valued at
1.5 MILES previously existing partnerships with $154,300.
these clinics, both of which Direct Relief The Community Health Clinic’s
has supported since 2009. To support the Executive Director, Barbara Bilton,
ACCESS’s efforts, Direct Relief provided reported that in each month since the
essential medical supplies and two grants tornado struck, the clinic continues to
totaling close to $50,000 to assist in see 200 patients affected by the disaster.
expanding its services in the community. According to Ms. Bilton, the total number
Direct Relief also supported ACCESS with of patients since the storm last year
donations of medical material aid valued continues to increase while funding
at $880,800. These donations helped opportunities dwindle and grants decrease
enable ACCESS to continue to treat people due to the economy. Ms. Bilton doesn’t
in the immediate aftermath as well as expect the economic impact on their
TORNADO PATH 1 MILE through their sustained recovery efforts. clinic to change. As Joplin recovers, it is

JOPLIN SAFETY NET CLINICS
Post-disaster, the need for medical clear that the work of nonprofit providers
support continues. Direct Relief donated such as ACCESS Family Care and the
JOPLIN CITY LIMITS
tetanus vaccines to the Community Health Community Clinic of Joplin were essential
ST. JOHN’S REGIONAL HOSPITAL, DESTROYED IN TORNADO
Clinic of Joplin to distribute to community in treating thousands of people in need.

THE STATE OF THE SAFETY NET 2012 // BACKGROUND DirectRelief.org/USA // 26

Venice Family Clinic,


/// ACKGROUND
B
Venice, California

Direct Relief USA and the Safety Net

Reaching 4 million
patients without
health insurance.

THE STATE OF THE SAFETY NET 2012 // BACKGROUND DirectRelief.org/USA // 27

S ince 1948, Direct Relief has
provided humanitarian assistance
to improve the health and quality of life of
NETWORKING 1,000 NONPROFIT CLINIC AND HEALTH CENTER CORPORATIONS—
THE LARGEST CHARITABLE MEDICINES PROGRAM IN THE U.S.
people affected by poverty and disasters
throughout the world by providing than $300 million (wholesale) in medical DIRECT RELIEF’S CLINIC AND HEALTH CENTER PARTNER NETWORK
essential material resources—medicine, resources to more than 1,000 nonprofit 11 million patients
medical supplies, and basic equipment clinic and health center corporations. 568
FQHC/LOOK-ALIKE
Direct Relief USA is the nation’s Direct Relief is recognized for its fiscal
leading nonprofit provider of donated strength, accountability and efficiency,
medicines to community clinics, free and consistently achieves top rankings
clinics, and community health centers from Forbes, Charity Navigator (including 352
for low-income patients without health “Top Charity” and “4-Stars”), the Better FREE CLINIC
insurance. It operates the largest Business Bureau, and Consumers Digest.
charitable medicines program of its In 2011, Forbes rated Direct Relief “100%
kind, and is the only nonprofit licensed to efficient” and “[Among the] 20 most 4
PUBLIC HEALTH
distribute medicine in all 50 states. Since efficient large U.S. charities.” DEPARTMENT
2004, Direct Relief USA has delivered more
55.4% 2
FQHC/LOOK-ALIKE 34.3% OTHER
FREE CLINIC
THE ONLY NONPROFIT LICENSED TO DISTRIBUTE PRESCRIPTION 99
MEDICINE IN ALL 50 STATES, AND THE ONLY NONPROFIT THAT IS A COMMUNITY CLINIC

VERIFIED ACCREDITED WHOLESALE DISTRIBUTOR BY THE
NATIONAL ASSOCIATION OF BOARDS OF PHARMACY.

9.7%
COMMUNITY
HOW IT WORKS

CLINIC
X% Rx
PUBLIC HEALTH
DEPARTMENT X%
OTHER

BASED ON DAILY INTERACTION DIRECT RELIEF NOTIFIES CLINIC AND HEALTH CENTER DIRECT RELIEF PHARMACISTS REVIEW ALL PRODUCTS ARE DELIVERED TO THE
WITH CLINIC PARTNERS, DIRECT PARTNERS OF AVAILABLE PRODUCTS THROUGH THE PRODUCT REQUESTS AND ADJUST AS NECESSARY PARTNERS COURTESY OF FEDEX,
RELIEF REQUESTS NEEDED DIRECT RELIEF NETWORK. CLINICS CAN PLACE A BASED ON THE AVAILABILITY OF REQUESTED FREE OF CHARGE, TO BE GIVEN TO
MEDICAL PRODUCTS FROM 150 REQUEST FOR DONATED PRODUCTS FOR THEIR LOW- PRODUCTS AND THE INFORMATION CLINICS PATIENTS.
HEALTHCARE COMPANIES. INCOME PATIENTS WITHOUT HEALTH INSURANCE. PROVIDE ABOUT THEIR HEALTH FACILITIES.

2012 State of the Safety Net

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