Community Health Centers’ Progress and Challenges in Meeting Patients’ Essential Primary Care Needs

Introduction

Across the United States, federally qualified health centers (FQHCs) provide accessible, comprehensive, and coordinated primary care to more than 30 million patients.¹ These community-based outpatient clinics fill a critical gap in the health care system, delivering primary care services to patients regardless of their ability to pay. Every year, they provide care to over 20 million people with low incomes, 17 million people of color, 15 million enrollees in Medicaid or the Children’s Health Insurance Program, and nearly 6 million people who are uninsured.² Patients also make up at least half of each FQHC’s governing board, helping ensure their services are reflective of community needs.

Community health centers (CHCs), as they will be called in this brief, provide low-cost, high-quality primary care. They regularly meet or exceed national benchmarks for hypertension and diabetes control, for example, while reducing costs for patients and payers compared to other care settings.³ CHCs also provide behavioral health care and nonclinical services like case management, enrollment assistance, transportation to appointments, and more, which improve patients’ health care access and outcomes. As rural hospitals across the U.S. close, they are helping address care needs in their communities.⁴

Community health centers deliver comprehensive care to their patients despite balancing tight budgets. They are funded primarily by a combination of Medicaid reimbursements, which are generally lower than those from Medicare and commercial insurance, and federal grant funding, which has not kept up with inflation.⁵ CHCs face persistent funding gaps as revenues and federal funding aren’t enough to cover the costs of care they provide to uninsured patients. Other challenges they face, including the financial and operational impacts of the COVID-19 pandemic, changes in Medicaid enrollment and associated reimbursements, and persistent workforce shortages, have posed threats over the years to daily operations and their long-term sustainability.⁶

This brief draws on findings from the 2024 Commonwealth Fund National Survey of Federally Qualified Health Centers, which engaged CHCs nationally to assess the extent to which they achieve the core functions of primary care — accessibility, comprehensiveness, and coordination — and the barriers they face in doing so. This brief reports on responses from 737 CHC leaders, including executive directors, clinical directors, or project directors, who were surveyed in fall of 2023 and spring of 2024 about care delivery, technology, workforce, and more. Using data from the 2018 version of this survey, we further explore how care delivery has changed over time.⁷ Given their role in filling care gaps in rural areas, we also evaluate differences between CHCs operating in rural and urban geographies (see “How We Conducted This Study” for more detail).

Survey Findings

Access to Care

Extended Hours

Access to primary care outside traditional business hours has been linked to reduced emergency department visits and lower rates of patients reporting they didn’t get the medical care they needed.⁸ Between 2018 and 2024, nearly all surveyed CHCs offered extended hours for patients in the mornings, evenings, and weekends. Fewer rural CHCs reported offering extended hours in 2024 than in 2018, but this number was not significantly lower than urban CHCs reporting extended hours in 2024.

Timely Appointments

Offering timely care to patients as their health care needs arise can help reduce morbidity and mortality associated with chronic conditions and prevent the need for emergency care.⁹ Community health centers have consistently offered timely care, with nearly all CHCs offering same-day or next-day appointments in 2018 and 2024. In 2024, there was some geographic variation, with more rural CHCs offering timely appointments than urban CHCs, perhaps reflecting their lower patient volume.

Telehealth Availability

At CHCs, the delivery of clinical and other health services by phone or video, or telehealth, has grown significantly since 2018, likely due to the COVID-19 pandemic.¹⁰ Telehealth can offer greater flexibility for patients and providers, particularly when receiving in-person care isn’t feasible. In 2024, the gap closed between rural and urban telehealth care, which is promising, as people living in rural areas face more barriers to accessing in-person health services, and studies have shown that telehealth use is associated with positive outcomes for rural patients and providers alike.¹¹

Telehealth Challenges

In addition to the barriers patients face when engaging with telehealth — including lacking access to broadband or technology — over 60 percent of CHCs report that the cost of maintaining a telehealth platform and the reimbursements they receive for these visits posed challenges. Rural CHCs are significantly more likely than urban ones to report that financial considerations were a challenge.

The financial challenges of telehealth are not new and could worsen in the future. Previous research found that insufficient reimbursements and the high cost of implementation posed barriers to CHCs both before the COVID-19 pandemic and after its peak.¹² While CHCs were offered special payment rates from Medicare to use telehealth during the COVID-19 pandemic, which helped make implementation feasible, these rates are set to expire at the end of 2024.¹³

Telehealth Advantages

Despite the challenges associated with implementing telehealth, community health centers recognize it benefits patients by improving access to, and timeliness of, care. Telehealth also allowed CHCs to offset the financial losses associated with the pandemic, such as revenue lost from decreased in-person visits.¹⁴

Sixty-one percent of CHCs report telehealth has improved patients’ access to specialty care, with no significant differences between rural and urban CHCs (data not shown). But other research has found that only 20 percent of CHCs use telehealth to communicate with specialists, indicating there is an opportunity to better leverage telehealth to coordinate patients’ care with specialists.¹⁵

Language Services Access

About a quarter of community health center patients are best served in a language other than English.¹⁶ To ensure their access to high-quality care, over two-thirds of all health centers provide interpreters or translation assistance, as well as medical information or forms in multiple languages or modes, such as electronic and paper. More urban CHCs provide these services than rural CHCs, likely a reflection of their patient population. Twenty-six percent of urban CHCs reported that at least half of their patients are best served in a language other than English, compared to 4 percent of rural CHCs (data not shown).

Workforce Shortages

Workforce shortages pose a significant barrier to providing timely access to care, and our survey reveals that shortages at community health centers have gotten significantly worse over time. Most CHCs reported significantly more shortages of physicians, nurses, and mental health providers in 2024 than in 2018. There were no significant differences in shortages by geography in 2024 (data not shown).

Slightly less than half of CHCs reported a shortage of advanced care practitioners in 2024, including physician assistants and nurse practitioners. These providers are playing a growing role in primary care delivery, in some cases taking on tasks previously delivered by physicians.¹⁷

Other research suggests CHCs believe attrition is the result of competition from larger health care organizations, which may offer greater financial opportunities for practitioners, and COVID-19’s effect on staff well-being.¹⁸

Comprehensiveness of Care

Behavioral Health Screening

Today, behavioral health issues, including substance use and mental health disorders, are the most common conditions associated with visits to community health centers — more so than hypertension and obesity.¹⁹ The majority of CHCs in 2024 reported screening all their patients for behavioral health needs, similar to 2018. Significantly more rural CHCs report screening their patients for behavioral health issues in 2024 compared to 2018, a promising development since rural areas historically have poor access to mental health care.²⁰

Behavioral Health Services

Community health centers offer a range of services to address patients’ emotional and behavioral health needs. Over 60 percent have behavioral health services available, including substance use disorder (SUD) treatment, medication-assisted treatment (MAT), or the use of prescription medications to treat substance use disorder, and short- and long-term mental health counseling. Significantly more CHCs now offer SUD treatment and MAT services compared to 2018, likely driven by the influx in federal grants in recent years aimed at expanding access to behavioral health services.²¹ Eighty-eight percent of CHCs also offer virtual SUD treatment, and 70 percent offer virtual mental health counseling in 2024 (data not shown; 2018 data not available).

Behavioral Health Coordination

More community health centers are screening for behavioral health needs and offering behavioral health services in 2024 (see the Behavioral Health Screening and Behavioral Health Services exhibits), but more CHCs are also reporting behavioral health workforce challenges. In addition to the 77 percent of CHCs that reported shortages of mental health professionals (see the Workforce Shortages exhibit), most CHCs reported a lack of behavioral health staff, both on-site and in the community, as challenges to addressing patients’ needs — significantly more than in 2018. This appears to be causing coordination issues, with 79 percent of CHCs in 2024 reporting difficulty obtaining timely appointments with off-site behavioral health specialists for patients (data not shown).

Screening for Social Needs

In 2024, significantly more community health centers reported screening patients for unmet social and economic needs, with no significant differences between rural and urban CHCs (data not shown). Sixty-seven percent of CHCs reported screening all patients for unmet social needs in 2024, compared to 40 percent in 2018 (data not shown).

Greater screening rates may be the result of increased recognition across the health system that social needs impact patients’ health outcomes and access to care. CHCs may also be responding to the needs of their disproportionately low-income patients, who tend to have great social and economic needs.²² This is consistent with a 2022 Commonwealth Fund survey that found physicians working in CHCs were more likely to screen their patients for social and economic needs than those in other care settings.²³

Coordination with Community-Based Organizations

While more CHCs reported coordinating patient care with community-based organizations (CBOs) to address patients’ social needs in 2024, less than two-thirds did so, indicating room to grow. Additionally, only a quarter of CHCs received a report back on patients from CBOs, an issue that has been documented in other settings.²⁴ These low numbers may represent insufficient capacity for coordination — CHCs reported that inadequate CBO staffing (54%) and insufficient social service resources in the community (56%) were major challenges to meeting their patients’ unmet needs in 2024 (data not shown).

Direct Provision of Social Services

More than half of all community health centers reported providing direct social services, such as healthy food or housing vouchers. Significantly more urban CHCs had these programs in place compared to rural CHCs. Community health centers’ ability to directly provide services may be affected by their finances, as 65 percent of all CHCs said that lack of financial resources to address unmet needs was a major challenge (data not shown).

Coordination of Care

Complex Care Management

Complex care management is an effective model for people with multiple physical, behavioral, or social needs, involving care managers coordinating and implementing patient care plans across providers and settings.²⁵ About half of CHCs provide complex care management, though significantly more rural CHCs do so, perhaps due to the higher needs of their patients or greater difficulty patients experience coordinating their care in rural areas.

Specialist Appointments

While community health centers accept all patients regardless of their insurance, the same is not true of specialists outside health centers. The majority of CHCs reported difficulty getting timely specialist appointments for their Medicaid patients or those without insurance, more so than for Medicare or privately insured patients. This aligns with other research showing fewer specialists accept Medicaid compared to Medicare or private insurance.²⁶

eConsults, a coordination tool where providers receive advice to inform patient care from specialists without the specialist having to see the patient, may be a solution. However, only 20 percent of CHCs in 2024 reported that they usually or often use eConsults to connect with specialists (data not shown), indicating gaps in access to specialty services.

Discussion

Our findings demonstrate that amid several major public health challenges — from COVID-19 to the behavioral health crisis — community health centers are continuing to provide millions of patients with accessible, comprehensive, and coordinated health care.²⁷ Since 2018, CHCs have maintained timely access to care for their patients, with nearly all consistently offering expanded hours and same- or next-day appointments, accompanied by a substantial rise in telehealth services. They also have made strides in making care more comprehensive for their patients by offering behavioral health services, particularly treatment for substance use disorders, and screening patients for social needs.

We found some differences between urban and rural community health centers. Urban CHCs were more likely to offer direct social services and translation assistance, while rural CHCs reported higher rates of same- or next-day appointments, behavioral health screening, and complex care management — although overall health centers reported high rates of offering these services regardless of geography. These differences could reflect CHCs adapting to the needs of their unique patient populations or differing financial and staffing capacities in rural and urban settings.

Despite their progress, community health centers are facing challenges that threaten their ability to continue offering high-quality care. They are increasingly reporting shortages across their workforce, and they struggle to coordinate with off-site specialists, behavioral health care, and community-based organizations.

These challenges could be exacerbated in the future, as community health centers already operate on thin financial margins due to their reliance on low Medicaid reimbursements and federal funds that have not kept up with inflation or the increased number of health centers.²⁸ Impacts of the COVID-19 pandemic and Medicaid eligibility redeterminations will likely continue to stress their finances.²⁹

Policymakers can take several steps to maintain improvements among community health centers and address remaining challenges:

• Reauthorize and expand the Community Health Center Fund. The Community Health Center Fund, a key source of federal funding, is periodically reauthorized by Congress and is currently slated to expire at the end of 2024. Congress can alleviate the funding uncertainty that CHCs are facing by reauthorizing multiyear funding for the program and increasing the amount of funding to keep up with inflation.³⁰ A recent report by the Congressional Budget Office found that increases in CHC funding, which Congress is considering, would yield savings by lowering Medicare and Medicaid expenditures through reductions in high-cost utilization like hospitalizations.³¹
• Grow the community health center workforce. To address the growing workforce shortages experienced by CHCs, Congress can expand recruitment, retention, and training programs that encourage providers to practice in medically underserved or rural areas, such as the National Health Service Corps and the Teaching Health Center Graduate Medical Education Program.³²
• Support the provision of telehealth. Given the reported benefits of telehealth for patients’ access to care and CHC finances, Congress can take steps to ensure CHCs have sufficient resources to continue offering telehealth, including by aligning telehealth reimbursement more closely with reimbursement for in-person care. Financial assistance could be targeted to rural community health centers, which reported financial challenges to offering telehealth at higher rates, and where telehealth could be critical for ensuring access to care. Congress also could extend federal flexibilities that enabled CHCs to implement and expand telehealth use during the pandemic, such as increased payment rates, which are set to expire at the end of 2024.
• Engage community health centers in payment reform. Beyond grant funding, policymakers can support CHCs’ engagement in value-based payment models, which offer more predictable, flexible funding and reward the provision of high-quality, comprehensive care.³³ Models could be designed to intentionally encourage and enable coordination between CHCs and specialists or other providers outside the CHC, which we found was a key gap. To ensure that CHCs engaging in value-based payment are successful, policymakers can offer upfront funding and technical assistance to support their transition.³⁴