The chief reason for the expansion: If millions of Americans join the health insurance rolls, they'll need somewhere to go to get care. "As people become insured, we have to make sure they have a place to access health services," Macrae says.
This was the experience in Massachusetts, which was famously on the vanguard of health reform when then-Governor Mitt Romney enacted the new law -- An Act Providing Access to Affordable, Quality, Accountable Health Care -- in 2006. One study found that the number of patients receiving care at community health centers grew 31 percent after Massachusetts implemented its health reform program. "Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there," the study authors wrote.
On a recent Monday afternoon, the waiting room at Erie Family Health Center's West Town Health Center on Chicago's West Side is full. Many patients stand because all the seats are taken. The waiting area is small but clean and brightly lit, and patients and staff speak in hushed tones to accommodate the tight quarters. In a typical day, the 24 doctors at this health center see more than 250 patients.
It's a diverse mix. A third of the patients are uninsured and 58 percent use Medicaid; the rest have Medicare or private insurance. Both Spanish and English are spoken. One thing many patients have in common, however, is multiple chronic conditions. Francis scans the computerized medical chart of one typical patient, who suffers from nearly 20 conditions—including macular degeneration, obesity, high cholesterol, and diabetes. "I don't think people truly understand this," he says, gesturing to the medical record, "when they talk about health care policy."
An FQHC's strength is its community focus. Some do train physicians in conjunction with medical schools, but medical research is not a high priority for most clinics. It's the neighborhood ties—the ability to speak the language, the affiliations with local institutions—that set them apart. "An FQHC isn't just a clinic—it's truly a community health center," says Cristina Sotelino, a spokesperson for Access Community Health Network, another large Chicago-area FQHC.
South Dakota is far away from the West Side of Chicago—geographically, demographically and economically. Politically, too: while Illinois has embraced Obamacare, strongly Republican South Dakota has largely rejected it, declining the ACA-related Medicaid expansion and choosing not to set up its own health insurance exchange. Instead, South Dakotans get access to the Federally Facilitated Exchange, which was set up by the federal government for states that didn't set up their own —and has been the subject of its own controversy because of its rocky rollout.)
Similarly, Horizon Health Care, based in Howard, S.D., is an FQHC that may not look like its big-city counterparts. Howard is a community of fewer than 1,000 people, and Horizon's Howard clinic sees just 14 to 20 patients a day. "Howard is a typical rural community," says CEO John Mengenhausen, who grew up in Howard. "We're all looking for new industry to come to town, and wondering how we can attract new families so our school system and Main Street remain viable. The FQHC plays a significant role in that.
Horizon boasts 17 care-delivery sites throughout South Dakota. More than a third of its patients are uninsured, and another 29 percent are on Medicaid. (Statewide, 13 percent of the state's 830,000 residents lack health insurance, according to the Henry J. Kaiser Family Foundation.)
So, just as in Chicago and other big cities, FQHCs in South Dakota are expanding and enrolling new patients. "We expect to see an increase in business, and we're preparing for it," Mengenhausen says. Horizon has received $111,000 in ACA money for outreach and enrollment, and approximately $1.4 million for expansion.
Rosenbaum says it's the intense community focus that ensures FQHCs' vitality, regardless of what happens with the ACA. "The great success of the program is that it never lost its community focus," she says. "If you put down solid roots, your staying power transcends whoever happens to be in office."