Community health centers are well positioned to expand vision care services such as vision testing and screening for glaucoma and retina disease to people who have difficulty getting that care, but they have been severely underused, according to a new analysis. And now they’re facing an unprecedented funding crisis.

The study comes at a time when community health centers known as Federally Qualified Health Centers (FQHCs) are entering a climate of uncertainty, first with the Trump administration’s freeze on government funding — which reportedly forced some facilities to close or cut staff — and, more recently, with talk of deep cuts to Medicaid, which accounted for 43% of the centers’ revenue in 2023. The freeze has been rolled back for now, but the agency that sends grants to FQHCs may lose funding in March if Congress doesn’t renew the spending.

“About 29% of FQHCs have onsite vision services, which is an increase compared to a few years back,” said Aiyin Chen, MD, an associate professor at the Casey Eye Institute of Oregon Health & Science University in Portland, Oregon, and senior author of the new analysis, which appeared in a recent issue of JAMA Ophthalmology. “But if you look at the percentage of patients in FQHCs who actually receive that care, it’s only 3%, which is clearly not enough.”

Chen and her colleagues assessed 43 studies of performance and outcomes of FQHCs over a 58-year period. They found 65.3% of patients at these facilities and free clinics have concerns about their eye health compared with 48% of the population overall.

Sally Ong, MD, an assistant professor of ophthalmology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, authored an invited commentary that she submitted long before the funding freeze and talk of Medicaid cuts.

“I agree that there is a lot of uncertainty on the status of FQHCs at the moment,” Ong told MedscapeMedical News.

“Preventing visual impairment and blindness by expanding vision services at FQHCs is not just the right thing to do, it also confers significant economic benefits to the community and the country in the long term” by reducing costs associated with medical care and nursing homes and lost wages and productivity, she said.

Ong cited a 2022 study showing vision impairment cost the US economy $134.2 billion per year, with nursing home care comprising the largest portion of that figure, at $41.8 billion.

FQHCs History and Outlook

First established in 1965, FQHCs receive federal funding to provide comprehensive primary care services in underserved areas. They draw funding through the Community Health Center Fund, operated under the Health Resources and Services Administration (HRSA), and must meet government standards for quality care for all patients regardless of their ability to pay. HRSA received $15.4 billion in funding in fiscal year 2024. The National Association of Community Health Centers (NACHC) estimated that 32.5 million people will visit FQHCs annually.

FQHCs offer a variety of health services beyond primary care and vision, including dental services, obstetrics and gynecology, physical therapy, behavioral health, and even transportation and case management. The centers serve 18% of all Medicaid recipients, accounting for about 2% of the program’s spending in 2022, NACHC reported. FQHCs also receive funding from states.

With 32,000 primary care providers (PCPs), they are the largest network of PCPs in the country, Amanda Pears Kelly, CEO of Advocates for Community Health, another FQHC national association, told Medscape Medical News.

“This is an uncertain time for health centers, as the Community Health Center Fund expires in March and Medicaid is being considered for major cuts,” Pears Kelly said.

The freeze the Office of Management and Budget imposed has been mostly resolved, although a few FQHCs are still dealing with funding “lags,” Pears Kelly said.

More recent talk of severe Medicaid cuts may be a bigger concern. Business Insider reported that the latest budget proposal from House Republicans includes trimming $880 billion from programs under the oversight of the House Energy and Commerce Committee and is likely to target Medicaid.

FQHCs and Vision Care

FQHCs are well positioned to increase vision services for an at-risk population because they’re a one-stop shop for healthcare services, Chen said. “It’s much more convenient to come to one place where they can get all the care instead of having to go to multiple different places, and a lot of these patients have transportation issues,” she said.

The systematic review found that compared with the overall population, patients at the centers have a 50% higher rate of visual impairment than the overall population, more than double the rate of glaucoma and diabetic retinopathy, almost double the rate of undercorrected refractive error (5.3% vs 10.4%), and a 50% higher rate of age-related macular degeneration.

To expand vision care services at FQHCs, policymakers should increase, not cut, Medicaid funding, Chen said. About half of all vision care arising from FQHCs relies on referrals to outside providers, and slashing Medicaid payments would only discourage providers from taking these patients, she said.

HRSA, the agency that oversees FQHCs, could also boost vision care by categorizing it as a core service, Chen said. “Once mental health was included [as a core service] that service doubled,” she said.

Beyond waiting for policymakers, FQHCs can partner with academic institutions to provide salary support for optometrists and ophthalmologists to provide vision care coverage in exchange for real-world experience for their trainees, Chen said.

One such model is the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine program. A 2023 study found an incidence of eye disease and vision problems among the program’s population that was in line with previously published disparities. In all, 71% of program participants received low-cost glasses and 41% were referred for follow-up with an ophthalmologist.

Telemedicine also is well suited for expanding vision care services, Chen said. “Not all services are easy to do telemedicine, but eye care can be because it is so image based,” she said.

Ophthalmic photographers can capture a diagnostic image at a remote location and send it to a telemedicine reading center for an opinion, she said. “It’s the fastest way to screen for patients who really need in-person service,” she said. Her group’s systematic analysis cited a 2012 study from Yale University that put the cost of a telemedicine screening program for diabetic retinopathy at $50, nearly $28 less than that for in-person screening.

FQHCs Making Their Case

Studies such as Chen’s can help FQHCs make their case for funding, Pears Kelly said. But she stressed the financial environment is “essentially at a breaking point.”

“Without additional funding and without significant investment in the program, we’re unfortunately going to see closures, we’re going to see furloughs, we’re going to see damage to continued care,” Pears Kelly added.

By the same token, she’s cautiously optimistic FQHCs can make their case to policymakers. “It’s a 60-year-old program this year, and there has been a long, long history of deep bipartisan support,” she said. “Both Republican and Democratic administrations have invested in it.”

Health and Human Services Secretary Robert F. Kennedy, Jr’s, “Make America Healthy Again” may offer a lifeline to FQHCs, Pears Kelly said. “That path to Make America Healthy Again is primary care,” she said. “That’s what health centers do. As the largest network of primary care providers in the country, there’s this optimism and even excitement around how we can be a part of that solution.”

The American Academy of Ophthalmology Task Force on Ophthalmology and Community Health Centers conducted the systematic analysis. Chen had no relevant disclosures. Ong disclosed financial relationships with AbbVie/Regenxbio, Apellis Pharmaceuticals, and EyePoint Pharmaceuticals.

Richard Mark Kirkner is a medical journalist based in Philadelphia.