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Objective: To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. Data sources: We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county-level characteristics from the Census Bureau. Our final dataset included 5841 center-year observations. Study design: We used difference-in-differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state-specific trend models, and placebo law tests as robustness checks. Data collection methods: Not applicable. Principal findings: On the revenue side, we found a $2.08 million relative increase (p = 0.002) in Medicaid revenues, offset by a $0.44 million decrease (p = 0.015) in total grants among community health centers in expansion states compared with centers in non-expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p = 0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p < 0.001) relative to their counterparts in non-expansion states. Conclusions: Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. While Medicaid revenue increased as a result of the policy, we find no major evidence of substitution away from other revenue lines, with one notable exception (i.e., substitution away from state and local government grants). From a policy perspective, these results are encouraging as the Biden Administration starts to implement the safety-net enhancements from the American Rescue Plan Act of 2021 and as more non-expansion states are considering opting into Medicaid expansions. It is anticipated that these added revenue streams will help to sustain health centers in the delivery of health care services to the underserved population. KEYWORDS Affordable Care Act, community health centers, Medicaid expansion What is known on this topic * Medicaid expansion has led to increased utilization of community health centers. * The early studies on the impact of Medicaid expansions on community health centers staffing were inconclusive. What this study adds * Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. * While Medicaid revenue increased as a result of the Medicaid expansion, we find no major evidence of substitution away from other revenue lines, with one exception (decreased grants)., 1 | INTRODUCTION Community health centers (CHCs) are 'community-based and patientdirected' not-for-profit organizations that deliver comprehensive primary care to medically underserved areas. CHCs serve primarily uninsured and Medicaid patients. In [...]

Objective: To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services. Data Sources: We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs. Study Design: We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function. Findings: Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ. Conclusion: As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs. KEYWORDS community health centers, production function, quality of care, workforce, 1 | INTRODUCTION Community health centers (CHCs) are important safety net providers. In 2016,1367 federally funded CHCs served 26 million patients or 1 in 12 Americans. (1-2) Health centers are [...]