Excerpted from: Brad Wright, Who Governs Federally Qualified Health Centers?, 38 Journal of Health Politics, Policy & Law 27 (February, 2013)
Federally qualified health centers (FQHCs) are primary care clinics that were first established in 1965 as part of President Lyndon Johnson's War on Poverty. Located in underserved areas, they maintain an "open door" policy, providing care regardless of an individual's ability to pay. Consequently, they serve a disproportionate share of uninsured individuals and Medicaid beneficiaries. Despite the challenges inherent in serving such vulnerable populations, FQHCs' success in providing access to highquality, cost-effective health care is well documented (Proser 2005). Recognizing this, Congress made a significant investment in FQHCs, permanently authorizing the program and dedicating $11 billion in a new FQHC trust fund as part of the Patient Protection and Affordable Care Act (Hall 2011).
A definning characteristic of FQHCs is their consumer governance mandate, which requires that at least 51 percent of the governing board must consist of consumers (i.e., patients) of the center. Furthermore, the board as a whole is required to "represent the individuals being served by the center" (Section 330 of the Public Health Service Act, 42 U.S.C. 254b ). According to the Health Resources and Services Administration (HRSA 1998a: 22), which administers the FQHC program:
Since the intent is for consumer board members to give substantive input into the health center's strategic direction and policy, these members should utilize the health center as their principal source of primary health care .... [In addition,] the board should be comprised of members with a broad range of skills and expertise. Finance, legal affairs, business, health, managed care, social services, labor relations and government are some examples of the areas of expertise needed by the board to fulfill its responsibilities.
The requirement for FQHCs to have consumer-majority governing boards originated from the participatory democracy of the civil rights movement and a strong sentiment of "anti-professionalism" that sought to empower the poor (Boone 1972). More recently, consumer governance has been heralded as a way to make FQHCs more responsive to their community's needs by giving a representative voice to a group of patients who are otherwise frequently underrepresented (Phillips 1998). In this view, the extent to which representatives share salient characteristics with those they represent (descriptive representation) is positively associated with the extent to which representatives advocate for the interests of those they represent (substantive representation) (Pitkin 1967). Indeed, the positive relationship between descriptive and substantive representation has been well established (Scherer and Curry 2010; Preuhs 2007; W„ngnerud 2009; Herrick 2009). Descriptive representation may especially improve substantive representation of the interests of disenfranchised and underrepresented groups in cases where disadvantaged groups do not trust those in power and where the views of the disadvantaged groups are not well known to persons outside the group (Mansbridge 1999; Dovi 2003).
However, no formal process is mandated for the identification and selection of consumer board members, and little is known about who actually governs these increasingly important health care organizations (Hollister 1974; Morone 1998; Peterson 1970). Prior studies have found consumer governance to be fraught with implementation challenges, including dominance by social elites (Robins and Blackburn 1974), low levels of consumer participation (Windle, Bass, and Taube 1974), and disparities in working knowledge between consumers and nonconsumers (Paap 1978). More recent evidence suggests that FQHC board chairs and executive directors may undermine the intent of the consumer governance requirement by identifying potential board members for their expertise and encouraging them to become consumers (Bracken 2007).
Despite the challenges inherent in achieving descriptive representation (Chesney 1982; Cross 2002; Lipsky and Lounds 1976) and the fact that disadvantaged groups lack the resources necessary to participate directly or engage their representatives to act on their behalf (Berinsky 2002; Verba, Schlozman, and Brady 1995), calls for direct citizen participation in health care persist (Morone and Kilbreth 2003). Further complicating matters is that while consumer governance may make organizations more responsive to patient demands, the potential technical expertise gap between consumers and nonconsumers may have important implications for organizational performance (LeRoux 2009). FQHC governing boards are required to simultaneously have a consumer majority and the technical and professional expertise required for effective governance. Given a limited number of board seats, striking this balance may prove a challenge. As John Gaventa (1998: 56) writes, "Mandates for participation from above' must be linked with pre-existing capacities for participation from below."' The typical low-income, poorly educated FQHC consumer may be best able to identify the community's needs but is unlikely to possess the technical and/or professional skills required for the complex task of FQHC governance.
In the current study I use mixed methods to describe the composition of FQHC governing boards, assess the extent to which consumer board members are socioeconomically representative of the FQHC patient population, and identify factors that predict variation in the consumer composition of FQHC governing boards. As FQHCs stand poised to play an even larger role in a reformed health care system, answering the decades-old question of who truly governs FQHCs is an important first step to better understanding the function of these important safety net providers. This study also speaks to the potential role of consumers as team members in a modern health care system seeking to provide patient-centered care (Martin and Finn 2011), improve the cultural competence of health care organizations (Blustein et al. 2011), and allay concerns about government control of decision making (Hsiao et al. 2011).
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Location is one of the most important determinants of FQHC board composition. FQHCs in urban locations have nearly 3 percentage points fewer nonrepresentative consumers on the board, though urbanicity is not associated with the proportion of representative consumers. In addition, compared with FQHCs in the Northeast, FQHCs in the South and West census regions have a lower proportion of nonrepresentative consumers and a higher proportion of representative consumers on the board. Perhaps also related to location, FQHCs with a migrant health center grant have on average 8.6 percentage points fewer nonrepresentative consumers and 6.4 percentage points more representative consumers on the board.
Case mix by gender, poverty level, and race were not significant predictors of board composition. However, insurance status was an important predictor of the proportion of nonrepresentative consumers on the board. FQHCs with a greater proportion of uninsured and/or Medicaid patients tended to have lower proportions of nonrepresentative consumers, while FQHCs with a greater proportion of Medicare patients tended to have higher proportions of nonrepresentative consumers. Insurance status did not affect the proportion of descriptive consumers. The year variables indicate that the proportion of nonrepresentative consumers on the board increased by more than 3 percentage points between 2003 and 2006. Conversely, while there was a decreasing trend in the proportion of representative consumers, it was not statistically significant. None of the community-level population demographics were statistically significant in either model; however, each additional nonprofit per 100,000 population is associated with a 0.21 percentage point increase in the proportion of nonrepresentative consumers on the board.
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Despite the requirement that a majority of board members must be consumers, the results of this study suggest that descriptive representation is lacking on most FQHC governing boards. While nearly two-thirds of board members are consumers, only about one-fourth are representative of typical FQHC patients. What is more, the method used to categorize consumer board members is likely to have overestimated the degree of descriptive representation. It is reasonable to assume that the true proportion of representative consumer board members may be closer to one in five. By contrast, the majority of consumer board members are not representative. While the board members in this group do report being FQHC patients, they also belong to a high-status group that includes physicians, lawyers, and other professionals.
The predictive modeling suggests that FQHCs in urban areas of the northeastern United States tend to have lower levels of consumer governance overall, especially as board size increases. Among consumers, certain factors seem to be associated with the representative-nonrepresentative mix on the board. For example, the positive association of both Medicare case mix and physicians as percentage of staff with nonrepresentative consumer board members suggests that perhaps older, retired professionals and physicians themselves may be the ones serving on the board. The lack of an association between aggregate patient and community demographics and board composition suggests that board member selection is highly targeted and is not limited in any way by the pool of potential available board members. And, importantly, the regression models confirm that boards are becoming less descriptively representative over time.
Data from qualitative interviews confirm the lack of descriptive representation and suggest that it is driven more by socioeconomic gaps than by differences in race, gender, or geographic residence. They also indicate that self-reported consumer status may be less than ideal in other important ways, as some self-reported consumers did not consider the FQHC their usual source of care, did not use the FQHC for primary care, or did not become consumers until after joining the board. All these characteristics suggest a lack of shared experiences between consumer board members and the typical FQHC patient that stands to make them less descriptively representative (Dovi 2003; Mansbridge 1999). This may have important implications for how well FQHCs are able to relate and respond to the needs of the communities they serve.
These findings are consistent with the well-documented struggles to achieve descriptive representation in the early days of the health center program (Hochbaum 1969; Hollister 1974; Hollister, Kramer, and Bellin 1974; Paap 1978; Paap and Hanson 1982; Peterson 1970; Thompson 1980). However, more recent empirical studies did not identify deficiencies in descriptive representation (Bracken 2007; Latting 1983; National Rural Health Association 2005). This can be explained by the fact that these more recent studies considered consumers a homogeneous or nearly homogeneous group.
The results of this study clearly demonstrate that consumer homogeneity is a strong assumption and that there are in fact considerable differences among consumer board members, especially socioeconomic status, which should be taken into consideration. The reality is that some consumer board members are more descriptively representative of the typical FQHC patient than others.
Yet just because the level of descriptive representation is much lower than might be expected given the requirement of a consumer majority, it is important not to overlook the fact that FQHC boards are composed on average of 20.-25 percent descriptively representative consumer board members. Given the obstacles to participation that members of this group tend to face, this level of descriptive representation is a notable achievement in and of itself. One can imagine, for example, how different the US Congress would look if it were to achieve this level of descriptive representation compared with the electorate. Moreover, even nominal consumer governance may yield community benefits (Banducci, Donovan, and Karp 2004). Thus the descriptive findings presented here should not be used to draw conclusions about the effectiveness of consumer governance.
This study has some limitations. While individual board members were coded into SOC groups as conservatively as possible, assumptions were made about the coding and categorization of board members. A cutoff of 200 percent of the federal poverty level for a family of four was assumed as the indicator of a high-status occupation. For single individuals or those in a smaller family, this will lead to a conservative estimate. However, for individuals from a larger family, this will tend to overstate income relative to poverty.
Furthermore, mean annual income for each occupation was used, although some occupations may have more variation in wages than others. For an individual at the lower end of the range, a higher mean income for the group may lead a descriptive consumer to be categorized as a non-descriptive consumer, while for individuals at the higher end of the range, a lower mean income for the group may lead a nonrepresentative consumer to be categorized as a representative consumer.
Finally, the use of average annual occupational income only directly accounts for one dimension of representativeness. While this measure is likely correlated with other dimensions such as education, it is not a perfect indicator. Consumer board members can be descriptively representative of the patient population in a variety of ways. Thus a continuous index--rather than a categorical measure--of descriptive representation would be the ideal solution. Unfortunately, no data were available to attempt this approach. The method used was conservative enough, however, to be confident that, if anything, the results may be understated.
Going forward, future studies of consumer governance should strive to identify relevant differences among consumer board members. While the Bureau of Primary Health Care requires consumer board members as a whole to "represent the individuals served by the health center in terms of race, ethnicity, and gender" (HRSA 1998a: 22), other important factors such as insurance status, income, and education level have not been addressed. Health status might also be an important factor, as patients who utilize more services (e.g., those with a chronic illness) are more knowledgeable about the care they receive and more comfortable voicing their concerns to decision makers than are patients who rarely use services (Schlesinger, Mitchell, and Elbel 2002).
Future studies might also focus on understanding barriers to descriptive representation and designing ways to enhance levels of descriptive representation in practice. Board composition is ultimately the result of board member selection. Prior qualitative research finds that FQHC staff often identify potential consumer board members without making their patient status a primary consideration in their selection, because it is challenging to find the expertise needed for governance among the FQHC's patient population (Bracken 2007). While the current study reinforces these findings, a longitudinal case study of select FQHCs could provide valuable data on actual board member selection processes. At the very least, further inquiry into the role and contributions of descriptively representative consumer board members is warranted.
To be able to answer these questions well, there is a need for HRSA to collect and share better data on FQHCs. For instance, it would be useful to have governance data on board member age, gender, race, education level, and income. It would also be helpful to collect data on how long consumer board members have been receiving care at the center and how many visits for care they make annually. Finally, HRSA should consider making FQHC governance data publicly available in an electronic format to facilitate continued research into an important aspect of one of the nation's most highly regarded safety net providers.
At the same time as the FQHC program has been permanently authorized and received the largest funding increase in its history, there is an ongoing debate about the effectiveness of consumer governance and the appropriateness of making certain federal funding contingent on having a consumer majority board. Many hospitals, free clinics, and other safety net providers without consumer majority boards are ineligible for the federal grant funds and enhanced Medicaid reimbursement rate that FQHCs enjoy.
While this study cannot speak directly to the effectiveness of consumer governance, it provides the first empirical evidence about the composition of FQHC governing boards and, given the limited involvement of descriptively representative consumers on the board, raises questions about the potential of consumer governance to affect health center outcomes. Answering these questions is essential to informing the policy debate over consumer governance in health care.