Community residential segregation and the local supply of federally qualified health centers

Federally qualified health centers (FQHCs) are a critical source of primary care for disadvantaged populations with limited access to care, serving nearly one of four low-income Americans (National Association of Community Health Centers 2009). Over 90 percent of health center patients report incomes below 200 percent of the federal poverty level and 75 percent are either uninsured or covered by Medicaid; 35 percent are Hispanic/Latino, and 27 percent are African American (Taylor 2010). In largely urban counties, limited access to care has been attributed to not only the uneven geographic distribution of providers but also to the disinclination of providers to care for disadvantaged groups, rather than an overall deficit in physician supply (Fossett and Peterson 1989; Greene, Blustein, and Weitzman 2006). Thus, a community may develop an FQHC to serve its underserved population despite the relative proximity to other providers (Salinsky 2010).1 That some counties may actually demand FQHCs despite adequate supply suggests that within-county provider imbalances occur (Gaskin et al. 2012). We hypothesize that how segregated a county is by race/ethnicity and income may contribute to the difficulty in fairly distributing its primary care workforce, thus strongly contributing to the interest of counties in developing FQHCs. Understanding the influence of such community stratification factors could inform the policy discussions on allocation of federal resources for community health centers and broaden the policy debate to social reforms that might be requisite in building a more effective primary care safety net. In this study, we address the impact of one aspect of community social stratification: residential segregation on FQHC supply. Residential segregation has been defined as “the degree to which two or more groups live separately from one another in different parts of the urban environment” (Massey and Denton 1988). Prior research has shown that residential segregation is associated with a number of disparities in access and quality of care, including reduced physician visits, fewer ambulatory surgical facilities, lower supply of general surgeons and colorectal subspecialists, lower odds of receipt of appropriate breast cancer care, and delayed time to renal transplantation (Rodriguez et al. 2007; Haas et al. 2008; Hayanga et al. 2009a, b; Gaskin et al. 2011). Furthermore, studies of residents of integrated communities have shown either elimination or reversal of racial disparities in health and health outcomes (Gaskin et al. 2009; LaVeist et al. 2011). In the context of FQHCs, residential segregation may contribute to the need for safety net primary care services through multiple mechanisms: (1) geographic segregation of health services, with physicians physically distant from low-income and minority populations; (2) increased physician preferences to serve patients of similar race and socioeconomic background; and, as a consequence of (2), (3) lower rates of physician participation in Medicaid in segregated areas (Fossett and Peterson 1989; Greene, Blustein, and Weitzman 2006). Using national administrative data linked with social indicators, we studied the 8-year period of FQHC expansion from 2000 to 2007 to test our hypothesis that residential segregation by income and residential segregation by race/ethnicity is associated with the local supply of FQHCs.