National analysis
FQHCs in 9 non-expansion states see far more uninsured patients
June 3, 2026 · 6 min read · Source: HRSA UDS 2024
TL;DR
- • Outside California and Texas, 1,256 community health centers run 15,308 sites for 25.5M patients. Their patients' coverage depends on the state.
- • In the 9 states that never expanded Medicaid, FQHCs run 26.5% uninsured — 9.8 points higher than the 16.7% in expansion states.
- • As the enhanced ACA premium tax credits expire at the end of 2025, that gap is set to widen in exactly these states — and FQHCs absorb it.
Every FQHC serves everyone who walks in, whether or not they can pay. How those patients are covered depends on one decision each state made years ago: whether to expand Medicaid under the Affordable Care Act. HRSA's 2024 Uniform Data System shows the result.
FQHCs outside California and Texas
Outside California and Texas, there are 1,256 FQHC organizations operating 15,308 service sites across 57 states and territories, serving 25.5M patients a year. Nationally, their payer mix is 44.4% Medicaid, 18.4% uninsured, and 12.2% Medicare. That national average hides the real story.
Expansion and non-expansion states
Split those health centers by their state's Medicaid decision and two very different groups appear:
| Expansion | Non-expansion | |
|---|---|---|
| States | 40 | 9 |
| Health centers | 991 | 232 |
| Patients | 20.3M | 4.6M |
| Uninsured | 16.7% | 26.5% |
| Medicaid | 46.4% | 33.6% |
The uninsured share runs 9.8 percentage points higher at non-expansion-state FQHCs, while Medicaid — the program that pays for care in expansion states — falls from 46.4% to 33.6%.
The coverage the ACA was designed to provide simply isn't there, so the health center becomes the coverage of last resort. The 9 non-expansion states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Wisconsin, Wyoming.
What changes in 2026
The enhanced ACA Marketplace premium tax credits — which made Marketplace coverage affordable for millions since 2021 — are scheduled to expire at the end of 2025. When they lapse, premiums jump and coverage falls fastest among the working-poor population that non-expansion states leave in the gap: too much income for limited Medicaid, too little to afford an unsubsidized plan.
Those patients don't disappear. They show up at the FQHC, uninsured.
Florida is the largest non-expansion state in this analysis. Its FQHCs carry one of the heaviest uninsured loads in the country. It will show first what the end of the premium credits does to health centers in a non-expansion state.
What FQHC leaders should model
If you lead a health center in a non-expansion state, your biggest risk is the self-pay and sliding-fee line. Medicaid work requirements matter more in expansion states.
Three things to model now: the share of your panel on subsidized Marketplace plans that lapse in 2026; your 340B savings, which scale with the volume that keeps the doors open; and where your state stands on any partial-coverage workaround.
The expansion divide shows up in the payer mix on next year's budget.
What to do this week
- Count how many of your patients are on subsidized Marketplace plans that lapse in 2026.
- Check how your 340B savings would change if uninsured visits rise.
- Ask your state primary care association whether your state is weighing a partial-coverage workaround.
Sources
- HRSA Uniform Data System (UDS) 2024 — patients + payer mix
- KFF — Status of State Medicaid Expansion Decisions
- KFF — Enhanced ACA premium tax credit expiry (2026)
Figures computed live from our national dataset (HRSA UDS 2024), patient-weighted. Excludes California and Texas, which have dedicated state dashboards.
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