Congressman Gene Green, a Texas democrat who is the U.S. Representative for Texas’s 29th congressional district, has been a long-time advocate for access to affordable health care. More than 10 years ago, he helped expand federally qualified health centers in his state, particularly in Houston, where he saw the greatest need for health care services due to pockets of low-income, uninsured populations.

“FQHCs are the facts on the ground and they have been for 50 years, but they are not as utilized as they should be,” says Green.

But that is likely to change. FQHCs, or community health centers as they are more generally referred to, will play a greater role as more people gain insurance coverage under the Affordable Care Act, especially for those with Medicaid coverage in states that chose to expand the program. Some states chose to opt out of the law’s Medicaid expansion following the Supreme Court’s ruling allowing them to do so.

The latest national figures find a 19 percent increase in Medicaid applications in states that expanded Medicaid after the ACA went into full effect.

“I think they [community health centers] will continue to serve a lot of Medicaid patients and be there for those who remain uninsured and serve those who become newly insured through exchange products,” says Dr. David Sandman, senior vice president of the New York State Health Foundation.

Community health centers are considered safety net providers. Traditionally, they have served uninsured and underserved populations in the U.S. Whereas a free clinic will be less inclined to care for those who gain insurance — just because they need to make services available to those who need it most — community health centers serve anyone, regardless of their ability to pay or their status with health insurance coverage. In a perfect world, they can also care for uninsured patients who present at emergency rooms for basic care. In fact, some hospitals are already working closely with community health centers to educate patients about health center services and even schedule appointment for them at nearby clinics.

Texas was one of the 21 states that chose not to expand Medicaid. Green isn’t pleased about that for many reasons — one being that he thinks more Medicaid patients would help community health centers in his state.

“If a Medicaid patient comes in they [community health center] get reimbursed extra compared to what a hospital or doctor gets reimbursed — this is to encourage them to be in underserved areas,” says Green.

Community health centers’ fundamental identity as safety net providers is likely to remain in place under the Affordable Care Act, but the law does envision them in a broader capacity as the backbone of the health care delivery system due to newly insured patients, many of them Medicaid patients.

“The expectation is that community health centers will double the patients they serve,” says Sandman.

Growth comes in many forms
Community health centers receive federal grant money in addition to funds they receive from public and private payors, which normally isn’t that much.

“Federal grant dollars act as a kind of last dollar pull for people who are uninsured,” says Dan Hawkins, senior vice president of public policy and research at the National Association of Community Health Centers.

Today, there are more than nine thousand community health center sites across the country. They are in every state and serve roughly 23 million people.

Despite the bipartisan support community health centers have received through the years, funding is always at stake. Under the Bush administration, community health centers grew from serving nine million to 18 million patients. President Bush admired what health centers represented and also saw them as one way to take the pressure off of hospital emergency rooms. The program was doubled again in 2010 through $11 billion in pre-appropriated, or guaranteed funding, in the ACA. But Congress has taken back one-third of that money in what Hawkins says is “not an anti-community health center vote, but an anti-Obamacare vote.” Most recently, a bill was approved to fund the government through this fiscal year that included 7 hundred million in new funding for community health centers. An even larger increase will occur in 2015, with a projected growth figure of serving 35 million patients by the end of that year.

Many community health centers have expanded by adding new sites of care in neighborhoods with a growing need. Others have renovated their existing buildings, or added more staff and services.

“The focus has always been on primary care but because there is often a gap in specialty care, some health centers have brought specialty services to their sites either by contracting with a physician or hiring one,” says Laurie Felland, senior health researcher at Mathematica, a policy research institute, who with her colleagues has been tracking health centers in 12 communities across the U.S. since 1995.

Delivering basic, primary health care and preventative medicine was the initial function of Medicaid. However, with the service being the sole health care option for many, some community health centers have experimented with ways to expand its role to offer specialty care as well. In addition to having specialists deliver care at a community health center site, sometimes it’s just a matter of making sure staff coordinates care for patients. Many community health centers see the demand for specialty care becoming more of an issue due to the coverage expansion under the law.

Community health centers only employ a handful of surgeons, although that is growing, according to Hawkins. And many of the specialties are sub-specialties of internal medicine like endocrinology for diabetes patients. Today, almost all centers provide dental coverage and primary care. Most centers have primary diagnostic tools like X-ray and ultrasound, with only a few offering higher level options like CT and MRI.

A provider of choice
Not only are community health centers expanding, but they are also working to stand out as providers of quality health care that put patients first. One example is the ongoing effort by community health centers to gain patient-centered medical home (PCMH) recognition by the National Committee for Quality Assurance (NCQA), which is a designated model of care that is coordinated and led by a team.

Hawkins says there are folks on the ground in every state serving as coaches to help community health centers complete the certificate for PCMH status. Today, more than half of the community health centers in the U.S. are PCMH certified, and Hawkins says the goal is to have all sites PCMH certified by next year.

It’s not a stretch to say that community health centers are working harder than ever to keep patients coming back.

According to Hawkins, community health centers have always faced challenges with funding, workforce and space, but a new challenges these days can be found in providing quality care, patient satisfaction and becoming a provider of choice.

“I think a little competition is helpful. It keeps everyone on their toes not only in terms of the clinical quality of care, but also client responsiveness,” says Hawkins.

Even though community health centers will likely continue to care for the growing Medicaid population under the law, many hope they will be a choice for the insured too, not a last resort.

“I think as people have coverage they will have more options and that’s a good thing — patients should have ability to vote with their feet and choose where they want to get care,” says Sandman.