The last shall be first? Mission versus margin and the role of consumer governance in federally qualified health centers

Federally qualified health centers (FQHCs) provide primary care services to a disproportionate number of low-income, uninsured patients. They are required to have a governing board of which at least 51% of the board members are FQHC consumers. The objective of this study is to evaluate the effect of FQHC board composition on service provision and financial performance.;In a multi-method study, I use six years of quantitative data from the Uniform Data System and Area Resource File, supplemented with four years of board data from FQHC grant applications. I classify board members as non-consumers, non-descriptive consumers (whose socioeconomic status does not resemble the typical FQHC patient), and descriptive consumers (whose socioeconomic status resembles the typical FQHC patient).;Using a mix of OLS and Poisson regressions with FQHC-level fixed effects, I model the relationship between the proportion of consumers on the board and a set of four missionoriented and four margin-oriented dependent variables. Using Chamberlain's conditional logistic regressions, I use board member characteristics to model both the likelihood of holding executive committee office and the likelihood of serving as board chair. To complement the statistical analysis, I conduct in-depth interviews with a purposive stratified sample of FQHC board members (N = 30) to obtain data on board function and board members' perceptions of consumer governance.;I find that a minority of board members are descriptive consumers, that descriptive consumers are less likely than others to hold board leadership positions, and that under certain conditions the proportion of descriptive consumers on the board is negatively associated with FQHC operating margin. The proportion of descriptive consumers on the board is not associated with other mission and margin variables. However, the composition of descriptive consumers on the executive committee is positively associated with both the scope of enabling services and financial self-sufficiency. Therefore, including descriptive consumers on the board, while excluding them from the executive committee, may mean enduring the financial disadvantages of consumer governance, without enjoying the potential advantages it brings to service provision and financial performance.