Medicaid Expansion And Grant Funding Increases Helped Improve Community Health Center Capacity

Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017

This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.

The effects of Medicaid expansions on dental services at federally qualified health centers

BACKGROUND

Federally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs.

METHODS

The authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects.

RESULTS

Expanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits.

CONCLUSIONS

Expanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services.

PRACTICAL IMPLICATIONS

As safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.

Racial Bias Correlates with States Having Fewer Health Professional Shortage Areas and Fewer Federally Qualified Community Health Center Sites

Federally Qualified Community Health Centers (FQHCs), serving Health Professional Shortage Areas (HPSAs), are fixtures of the healthcare safety net and are central to healthcare delivery for African Americans and other marginalized Americans. Anti-African American bias, tied to anti- "welfare" sentiment and to a belief in African Americans' supposed safety net dependency, can suppress states' willingness to identify HPSAs and to apply for and operate FQHCs. Drawing on data from n = 1,084,553 non-Hispanic White Project Implicit respondents from 2013-2018, we investigated associations between state-level implicit and explicit racial bias and availability of FQHCs and with HPSA designations. After controlling for states' sociopolitical conservatism, wealth, health status, and acceptance of the Affordable Care Act's Medicaid expansion, greater racial bias was correlated with fewer FQHC delivery sites and fewer HPSA designations. White's bias against African Americans is associated with fewer FQHC opportunities for care and fewer identifications of treatment need for African Americans and other low-income people lacking healthcare options, reflecting bias-influenced neglect.

Louisiana Medicaid Expansion and Pent-Up Demand

BACKGROUND

Nearly half a million newly eligible people enrolled in Louisiana Medicaid following its expansion.

OBJECTIVES

To evaluate postexpansion utilization trends in Louisiana Medicaid.

RESEARCH DESIGN

We plotted utilization trends for expansion and traditional Medicaid beneficiaries and conducted regression analyses to evaluate differences in monthly trends for over 2 years following expansion.

SUBJECTS

We restricted our sample to a balanced panel of beneficiaries aged 18-64. The expansion population included beneficiaries who enrolled in the first month of eligibility. The nonexpansion group enrolled at least a year pre-expansion.

MEASURES

Monthly office visits, emergency department visits, and inpatient stays per 1000 enrollees, drawn from the Louisiana Medicaid Data Warehouse claims database.

RESULTS

Compared with trends among traditional Medicaid beneficiaries, expansion beneficiaries utilized 4.59 [ P =0.08] more monthly office visits per 1000 enrollees in their first year, increasing to 6.33 [ P <0.01] more per month thereafter. Monthly emergency department visit trends were not statistically significantly different in the first year but were 0.71 [ P <0.01] monthly visits lower for expansion beneficiaries thereafter. Trends in monthly inpatient stays were 0.23 [ P =0.02] stays per 1000 enrollees higher in the first year for expansion beneficiaries but were not statistically significantly different thereafter.

CONCLUSIONS

Louisiana Medicaid expansion beneficiaries experienced lower initial rates of office visits compared with traditional Medicaid beneficiaries, but these rates consistently increased over the first 2 years after expansion. The expansion population had uniformly higher levels of emergency department and inpatient visits throughout the study period. After the first postexpansion year, emergency department visits among expansion beneficiaries fell relative to traditional beneficiaries while inpatient utilization trends leveled off after an initial increase.

Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016

BACKGROUND

The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown.

OBJECTIVE

To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states.

RESEARCH DESIGN

Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering.

SUBJECTS

In total, 7058 census tracts across 10 states.

RESULTS

FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents.

CONCLUSION

Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.

Estimating the Impact of Medicaid Expansion and Federal Funding Cuts on FQHC Staffing and Patient Capacity

Policy Points In the preexpansion period, federally qualified health centers (FQHCs) in Medicaid expansion states were significantly different from those in nonexpansion states. This gap widened as revenues in expansion states continued to grow at a faster rate after the expansion. If Medicaid expansion had occurred nationwide, FQHCs' revenue and capacity could have increased substantially. Over time, Medicaid could play a bigger role as it becomes a more stable funding source to allow for capital investments. Section 330 grants appear to have a larger impact on access to care. Given the varying levels of reliance on Medicaid, investing through federal grants might be more effective and equitable.

CONTEXT

The Health Resources and Services Administration's Health Center Program (HCP) plays a critical role as the national ambulatory safety net, delivering services to patients in medically underserved areas, regardless of their ability to pay. As the program has grown, health policy initiatives may have altered access to care for the underserved population. Understanding how federally qualified health centers (FQHCs) have been affected by past policies is important for anticipating the effects of future policies.

METHODS

By analyzing a national data set from the Uniform Data System, we examined, using two sets of random effects regressions, the potential impact of alternative policy actions affecting FQHCs. Our primary equation models the number of full-time equivalent staff, of patients served, and of visits provided in the subsequent year as a function of Medicaid revenues, Section 330 grants, and other revenues. Our secondary equation is a difference-in-differences analysis that models Medicaid revenues as a function of the states' status of Medicaid expansion.

FINDINGS

The expansion of Medicaid in nonexpansion states could have increased Medicaid revenues by 138%, staffing by 25%, and patients' visits by 24% in 2017. Compared to the impact of a "repeal" of Medicaid expansion, the percentage of reductions in staffing would be similar to those predicted by a 50% cut in Medicaid revenues or in Section 330 grants. On a dollar-for-dollar basis, the effects of one dollar of Section 330 grants were more than double that of one dollar of Medicaid revenue.

CONCLUSIONS

Both Medicaid eligibility and Section 330 funding support are important to the HCP, and Section 330 grants are particularly closely related to staffing and the provision of services. States' decisions not to participate in or to repeal Medicaid expansion, to reduce Medicaid payment rates, and federal funding cuts all could have a negative impact on FQHCs, resulting in thousands of low-income patients losing access to primary care.

Antecedents of geographical expansion: The case of federally qualified health centers

BACKGROUND

Federally qualified health centers (FQHCs) are pivotal safety net primary care providers for the medically underserved. FQHCs have complex organizational designs, with many FQHCs providing care at multiple physical locations ("sites"). The number of sites, however, varies considerably between FQHCs, which can have important implications for differential access that may perpetuate disparities in quality of care.

PURPOSE

The objective of this study is to explore the organizational and environmental antecedents of the number of sites operated by each FQHC. The findings of this study contribute to a better understanding of FQHCs' expansion that has vital implications for cost and access outcomes.

METHODOLOGY/APPROACH

The study is based on data between the years 2012 and 2018. Using multivariate growth curve modeling, we analyzed the final sample, consisting of 5,482 FQHC-years.

RESULTS

The level of competition, measured as the number of FQHC sites in the Primary Care Service Area (PCSA) and the number of primary care physicians per 1,000 PCSA residents, was positively associated with the number of FQHC sites. The number of patients, the level of federal grant, and the year were also positively associated with the number of FQHC sites, whereas percentage of Medicaid patients; workforce supply, measured as primary care physician assistants per 1,000 PCSA residents; Medicaid expansion; and state/local funding available for FQHCs were not.

CONCLUSION

Findings of this study indicate that competition, especially between peer FQHCs, is significantly associated with FQHC expansion.

PRACTICE IMPLICATIONS

This result suggests that FQHC managers and policymakers may closely monitor cost, access, and quality implications of competition and FQHC expansion.

Impact of the Affordable Care Act Medicaid expansion on oral surgery delivery at community health centers: an observational study

BACKGROUND

Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs.

METHODS

Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations.

RESULTS

Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01).

CONCLUSIONS

Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

Financial impacts of the Medicaid expansion on community health centers

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.

Associations of Medicaid Expansion With Access to Care, Severity, and Outcomes for Acute Ischemic Stroke

BACKGROUND

Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke.

METHODS

A retrospective, difference-in-differences analysis of Get With The Guidelines-Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability.

RESULTS

In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12-1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08-1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80-0.98]). Expansion was not associated with any other outcomes.

CONCLUSIONS

Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.

Mapping the Location of Health Centers in Relation to "Maternity Care Deserts": Associations With Utilization of Women's Health Providers and Services

BACKGROUND AND OBJECTIVES

The aim was to explore the association between community health centers' (CHC) distance to a "maternity care desert" (MCD) and utilization of maternity-related health care services, controlling for CHC and county-level factors.

MEASURES

Utilization as: total number of CHC visits to obstetrician-gynecologists, certified nurse midwives, family physicians (FP), and nurse practitioners (NP); total number of prenatal care visits and deliveries performed by CHC staff.

RESEARCH DESIGN

Cross-sectional design comparing utilization between CHCs close to MCDs and those that were not, using linked 2017 data from the Uniform Data System (UDS), American Hospital Association Survey, and Area Health Resource Files. On the basis of prior research, CHCs close to a "desert" were hypothesized to provide higher numbers of FP and NP visits than obstetrician-gynecologists and certified nurse midwives visits. The sample included 1261 CHCs and all counties in the United States and Puerto Rico (n=3234).

RESULTS

Results confirm the hypothesis regarding NP visits but are mixed for FP visits. CHCs close to "deserts" had more NP visits than those that were not. There was also a dose-response effect by MCD classification, with NP visits 3 times higher at CHCs located near areas without any outpatient and inpatient access to maternity care.

CONCLUSIONS

CHCs located closer to "deserts" and NPs working at these comprehensive, primary care clinics have an important role to play in providing access to maternity care. More research is needed to determine how best to target resources to these limited access areas.

Association of Medicaid Expansion With 5-Year Changes in Hypertension and Diabetes Outcomes at Federally Qualified Health Centers

Question

What has been the 5-year association of Medicaid expansion with uninsurance rates, hypertension and diabetes outcomes, and racial and ethnic differences in outcomes in a national sample of federally qualified health centers (FQHCs)?

Findings

In this cohort study using a difference-in-differences analysis of 946 FQHCs that serve 18.9 million patients per year, Medicaid expansion-state FQHCs experienced improved blood pressure and glucose control measures over 5 years overall and for Black and Hispanic patients compared with FQHCs in nonexpansion states. Expansion was also associated with sustained reductions in uninsurance at FQHCs.

Meaning

The findings of this cohort study suggest that Medicaid expansion was associated with better 5-year health performance outcomes for FQHCs, which may be important for states that are considering Medicaid expansion.

Importance

State decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown.

Objective

To assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs.

Design, Setting, and Participants

Using a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021.

Exposures

Location in a state that expanded Medicaid eligibility as of 2014.

Main Outcomes and Measures

Rates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity.

Results

Of the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations.

Conclusions and Relevance

In this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic populations. States considering Medicaid expansion may benefit from improved longer-run health measures for underserved patients with chronic conditions.

Quality and Cost in Community Health Centers

BACKGROUND

Quantifying health care quality has long presented a challenge to identifying the relationship between provider level quality and cost. However, growing focus on quality improvement has led to greater interest in organizational performance, prompting payers to collect various indicators of quality that can be combined at the provider level.

OBJECTIVE

To explore the relationship between quality and average cost of medical visits provided in US Community Health Centers (CHCs) using composite measures of quality.

RESEARCH DESIGN

Using the Uniform Data System collected by the Bureau of Primary Care, we constructed composite measures by combining 9 process and 2 outcome indicators of primary care quality provided in 1331 US CHCs during 2015-2018. We explored different weighting schemes and different combinations of individual quality indicators constructed at the intermediate domain levels of chronic condition control, screening, and medication management. We used generalized linear modeling to regress average cost of a medical visit on composite quality measures, controlling for patient and health center factors. We examined the sensitivity of results to different weighting schemes and to combining individual quality indicators at the overall level compared with the intermediate domain level.

RESULTS

Both overall and domain level composites performed well in the estimations. Average cost of a medical visit was negatively associated with quality, although the magnitude of the effect varied across weighting schemes.

CONCLUSION

Efforts toward improvement of primary health care quality delivered in CHCs need not involve greater cost.

Receipt of Social Needs Assistance and Health Center Patient Experience of Care

INTRODUCTION

Community health centers often screen for and address patients' unmet social needs. This study examines the degree to which community health center patients report receiving social needs assistance and compares measures of access and quality between patients who received assistance versus similar patients who did not.

METHODS

A nationally representative sample of 4,699 nonelderly adults receiving care at community health centers from the 2014-2015 Health Resources and Services Administration Health Center Patient Survey was used, representing 12.6 million patients. The exposure-having "received social needs assistance"-was based on whether a patient received any community health center assistance accessing social programs (e.g., applying for government benefits) or basic needs (e.g., obtaining transportation, housing, food). Using logistic regression models with inverse probability of treatment weights, outcomes for patients who received social needs assistance with similar patients who did not were compared. Study outcomes, reported as absolute adjusted differences, included reporting a community health center as a usual source of care, reporting the emergency department as a usual source of care, perceived quality of care, and willingness to recommend the community health center to others. Data were analyzed in 2020.

RESULTS

Of the sample, 36% reported receiving social needs assistance, where the most common form of assistance was applying for government benefits. Relative to similar patients who did not receive social needs assistance, patients receiving assistance were significantly more likely to report a community health center as their usual source of care (adjusted difference=7.2 percentage points, 95% CI=2.2, 12.1) and to report perceived quality of care as "the best" (adjusted difference=11.1, 95% CI=5.4, 16.9). They were significantly less likely to report the emergency department as their usual source of care (adjusted difference= -4.2, 95% CI= -7.0, -1.3).

CONCLUSIONS

As community health centers and other providers consider providing social needs assistance to patients, these results suggest that doing so may be associated with improved access to and quality of care.

Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion

The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) providing primary care in medically-underserved communities. However, beyond evidence of initial policy effects, little is understood in the scholarly literature about whether the ACA Medicaid expansion affected longer-lasting changes in CHC patient insurance mix. This study's objective was to examine whether the ACA Medicaid expansion was associated with lasting increases in the annual percentage of adult CHC patients covered by Medicaid and decreases in the annual percentage of uninsured adult CHC patients at expansion-state CHCs, compared to non-expansion-state CHCs. This observational study examined 5353 CHC-year observations from 2012 to 2018 using Uniform Data System data and other national data sources. Using a 2-way fixed-effects multivariable regression approach and marginal analysis, intermediate-term policy effects of the Medicaid expansion on annual CHC patient coverage outcomes were estimated. By 5-years post-expansion, the Medicaid expansion was associated with an overall average increase of 11.7 percentage points in the percentage of adult patients with Medicaid coverage at expansion-state CHCs, compared to non-expansion-state CHCs. Among expansion-state CHCs, 39.8% of adult patients were predicted to have Medicaid coverage 5-years post-expansion, compared to 19.0% of non-expansion-state adult CHC patients. A state's decision to expand Medicaid was similarly associated with decreases in the annual percentage of uninsured adult CHC patients. Primary care operations at CHCs critically depend on patient Medicaid revenue. These findings suggest the ACA Medicaid expansion may provide longer-term financial security for expansion-state CHCs, which maintain increases in Medicaid-covered adult patients even 5-years post-expansion. However, these financial securities may be jeopardized should the ACA be ruled unconstitutional in 2021, a year after CHCs experienced new uncertainties caused by COVID-19.

Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States

Background:

The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers.

Methods:

Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 non-expansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid.

Results:

Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51–2.60; and 1.98; 95% confidence interval, 0.91–3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: −4.21; 95% confidence interval, −6.98 to −1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states.

Conclusions:

Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.

Medicaid Expansion and Racial/Ethnic Differences in Readmission After Acute Ischemic Stroke

To examine whether rates of 30-day readmission after acute ischemic stroke changed differentially between Medicaid expansion and non-expansion states, and whether race/ethnicity moderated this change, we conducted a difference-in-differences analysis using 6 state inpatient databases (AR, FL, GA, MD, NM, and WA) from the Healthcare Cost and Utilization Project. Analysis included all patients aged 19-64 hospitalized in 2012–2015 with a principal diagnosis of ischemic stroke and a primary payer of Medicaid, self-pay, or no charge, who resided in the state where admitted and were discharged alive (N=28 330). No association was detected between Medicaid expansion and readmission overall, but there was evidence of moderation by race/ethnicity. The predicted probability of all-cause readmission among non-Hispanic White patients rose an estimated 2.6 percentage points (or 39%) in expansion states but not in non-expansion states, whereas it increased by 1.5 percentage points (or 23%) for non-White and Hispanic patients in non-expansion states. Therefore, Medicaid expansion was associated with a rise in readmission probability that was 4.0 percentage points higher for non-Hispanic Whites compared to other racial/ethnic groups, after adjustment for covariates. Similar trends were observed when unplanned and potentially preventable readmissions were isolated. Among low-income stroke survivors, we found evidence that 2 years of Medicaid expansion promoted rehospitalization, but only for White patients. Future studies should verify these findings over a longer follow-up period.

The impact of funding for federally qualified health centers on utilization and emergency department visits in Massachusetts

Importance

Federally qualified health centers (FQHCs) receive federal funding to serve medically underserved areas and provide a range of services including comprehensive primary care, enabling services, and behavioral health care. Greater funding for FQHCs could increase the local availability of clinic-based care and help reduce more costly resource use, such as emergency department visits (ED).

Objective

To examine the impact of funding increases for FQHCs after the ACA on the use of FQHCs and EDs.

Methods

Retrospective study using the Massachusetts All Payer Claims Database (APCD) 2010–2013 that included APCD enrollees in 559 Massachusetts ZIP codes (N = 6,173,563 in 2010). We calculated shift-share predictions of changes in FQHC funding at the ZIP code-level for FQHCs that received Community Health Center funds in any year, 2010–13 (N = 31). Outcomes were the number of ZIP code enrollees with visits to FQHCs and EDs, overall and for emergent and non-emergent diagnoses.

Results

In 2010, 4% of study subjects visited a FQHC, and they were more likely to be younger, have Medicaid, and live in low-income areas. We found that a standard deviation increase in prior year FQHC funding (+31 percentage point (pp)) at the ZIP code level was associated with a 2.3pp (95% CI 0.7pp to 3.8pp) increase in enrollees with FQHC visits and a 1.3pp (95% CI -2.3pp to -0.3pp) decrease in enrollees with non-emergent ED visits, but no significant change in emergent ED visits (0.3pp, 95% CI -0.8pp to 1.4pp).

Conclusions

We found that areas exposed to greater FQHC funding increases had more growth in the number of enrollees seen by FQHCs and greater reductions in ED visits for non-emergent conditions. Investment in FQHCs could be a promising approach to increase access to care for underserved populations and reduce costly ED visits, especially for primary care treatable or non-emergent conditions.

New hypertension and diabetes diagnoses following the Affordable Care Act Medicaid expansion

OBJECTIVE

To assess the Affordable Care Act (ACA) Medicaid expansion's impact on new hypertension and diabetes diagnoses in community health centres (CHCs).

DESIGN

Rates of new hypertension and diabetes diagnoses were computed using generalised estimating equation Poisson models and we tested the difference-in-difference (DID) pre-ACA versus post-ACA in states that expanded Medicaid compared with those that did not.

SETTING

We used electronic health record data (pre-ACA: 1 January 2012-31 December 2013-post-ACA: 1 January 2014-31 December 2016) from the Accelerating Data Value Across a National Community Health Center Network clinical data network. We included clinics with ≥50 patients contributing to person-time-at risk in each study year.

PARTICIPANTS

Patients aged 19-64 with ≥1 ambulatory visit in the study period were included. We then excluded patients who were pregnant during the study period (N=127 530). For the hypertension outcome, we excluded individuals with a diagnosis of hypertension prior to the start of the study period, those who had a hypertension diagnosis on their first visit to a clinic or their first visit after 3 years without a visit, and those who had a diagnosis more than 3 years after their last visit (pre-ACA non-expansion N=130 973; expansion N=193 198; post-ACA non-expansion N=186 341; expansion N=251 015). For the diabetes analysis, we excluded patients with a diabetes diagnosis prior to study start, on their first visit or first visit after inactive patient status, and diagnosis while not an active patient (pre-ACA non-expansion N=145 435; expansion N=198 558; post-ACA non-expansion N=215 039; expansion N=264 644).

RESULTS

In non-expansion states, adjusted hypertension diagnosis rates saw a relative decrease of 6%, while in expansion states, the adjusted rates saw a relative increase of 7% (DID 1.14, 95% CI 1.11 to 1.18). For diabetes diagnosis, adjusted rates in non-expansion states experienced a significant relative increase of 28% and in expansion states the relative increase was 25%; yet these differences were not significant pre-ACA to post-ACA comparing expansion and non-expansion states (DID 0.98, 95% CI 0.91 to 1.05).

CONCLUSION

There was a differential impact of Medicaid expansion for hypertension and diabetes diagnoses. Moderate increases were found in diabetes diagnosis rates among all patients served by CHCs post-ACA (both in expansion and non-expansion states). These increases suggest that ACA-related opportunities to gain health insurance (such as marketplaces and the Medicaid expansion) may have facilitated access to diagnostic tests for this population. The study found a small change in hypertension diagnosis rates from pre-ACA to post-ACA (a decrease in non-expansion and an increase in expansion states). Despite the significant difference between expansion and non-expansion states, the small change from pre-ACA to post-ACA suggests that the diagnosis of hypertension is likely documented for patients, regardless of health insurance availability. Future studies are needed to understand the impact of the ACA on hypertension and diabetes treatment and control.

Communicating a Complicated Medicaid Waiver Program to Enrollees in Iowa: How Federally Qualified Health Centers Support Medicaid Members

Iowa expanded Medicaid eligibility with a waiver including a personal responsibility component. Early program evaluation revealed low compliance and awareness among members. There is little research on leveraging existing contact points in the health care system to effectively communicate with Medicaid enrollees. We interviewed outreach and enrollment staff at Federally Qualified Health Centers (FQHCs) to explore their work. We show that FQHCs use several strategies to enroll individuals in appropriate programs and support them in understanding and navigating their health insurance coverage. With increasingly complex Medicaid programs, this support will be more widely needed to prevent hardship and loss of coverage.

Optimal staffing in community health centers to improve quality of care

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.

Enhancing Staffing In Rural Community Health Centers Can Help Improve Behavioral Health Care

Community health centers are a vital part of the primary and behavioral health care systems in rural areas. We compared behavioral health care staffing and services in rural and urban centers. In the period 2013-17 the overall staff-to-patient ratio in behavioral health rose by 66 percent in rural centers, faster than growth in urban centers (49 percent). Growth in both settings was mostly driven by clinical social workers and other licensed mental health providers; staffing by psychiatrists and psychologists changed only slightly. In rural centers the average adjusted increase in annual visits per additional behavioral health staff member was 411 for substance use disorders, slightly higher than at urban centers. Additional annual visits per additional staff member in rural centers were 539 for depression, 466 for anxiety, and 300 for other mental disorders, similar to the numbers in urban centers. Behavioral health staff currently participating in the National Health Service Corps (NHSC) contributed more to visits for depression and anxiety in rural centers, compared to both their urban counterparts and non-NHSC staff in rural centers. Enhancing behavioral health staffing in rural community health centers could help reduce the urban-rural gap in the availability of behavioral health services, but still more could be done.

Impact of oral health service expansion funding at health centers in the United States

OBJECTIVES

This study aims to assess the impact of Health Resources and Services Administration (HRSA) investment in oral health through the HRSA FY16 Oral Health Service Expansion (OHSE) funding on workforce, access, and quality in health centers (HCs) from 2015 to 2017.

METHODS

Analyses were conducted using data from the Uniform Data System from 2015 and 2017, and the 2015 Area Health Resource File. Change in indicators of oral health workforce, access, and quality of care by the receipt of OHSE funding received by HCs in 2016 were examined. Regression models for 1,345 HCs were developed to conduct a difference-in-difference analyses of the comparative change from 2015 to 2017 in the dependent variables among OHSE and non-OHSE awardees while controlling for confounders.

RESULTS

OHSE awardees showed a significant difference in the oral health workforce with a higher mean number increase by 0.6 full time equivalent (FTE) dentists, 0.4 dental hygienists, 1.1 dental assistants, and 2.3 for other dental staff compared to non-OHSE awardees. Compared to non-OHSE awardees, OHSE awardees showed a mean increase of 712 dental patients served who received 1,402 dental visits, representing a 9-percentage point increase in the percentage of HCs that had an oral health program and a 3-percentage point increase in the ratio of dental patients to total patients.

CONCLUSIONS

Funding dedicated to oral health service expansion in HCs may result in outcomes ranging from increasing workforce to reduction in access and financial barriers. Retrospective analysis demonstrated improved capacity for oral healthcare delivery attributable to HRSA support to HCs.

Addiction Treatment Capacity in Health Centers: The Role of Medicaid Reimbursement and Targeted Grant Funding

OBJECTIVE

Expanding access to addiction screening and treatment in primary care, particularly in underserved communities, is a key part of the fight against the opioid epidemic. This study explored correlates of addiction treatment capacity in federally qualified health centers participating in the Midwest Clinicians' Network (MWCN).

METHODS

Two surveys were fielded to 132 MWCN health centers: the Health Center Survey and the Behavioral Health and Diabetes Provider Survey. A total of 77 centers and 515 primary care clinicians, respectively, responded to the surveys. Data were combined with data from the 2016 Uniform Data System and information about receipt of targeted Health Resources and Services Administration (HRSA) grant funding for addiction treatment capacity. Multivariable models examined associations between Medicaid reimbursement for addiction services, HRSA targeted grant funding, and different types of on-site addiction treatment capacity: psychiatrist and certified addiction counselor staffing, addiction counseling services, and medication-assisted treatment (MAT) for opioid addiction.

RESULTS

Health centers that received Medicaid behavioral health reimbursement were five times as likely as those that did not to offer addiction counseling and to employ certified addiction counselors. Health centers that received targeted HRSA funding for addiction services were more than 20 times as likely as those that did not to provide MAT and more than three times as likely to employ psychiatrists. Training needs and privacy protections on data related to addiction treatment were cited as barriers to building addiction treatment capacity.

CONCLUSIONS

Medicaid funding and targeted grant funding were associated with addiction treatment capacity in health centers.

The context, strategy and performance of the American safety net primary care providers: a systematic review

PURPOSE

The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided.

DESIGN/METHODOLOGY/APPROACH

A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases.

FINDINGS

28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance.

ORIGINALITY/VALUE

Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.

Predicting the Impact of Transforming the Medicaid Program on Health Centers' Revenues and Capacity to Serve Medically Underserved Communities

Policy Points Recent federal proposals to use block grants or per capita caps to fund Medicaid would likely lead to cuts in Medicaid funding for health centers, which are an important source of care for Medicaid enrollees. Recent Medicaid §1115 waivers are seeking to change state-level enrollment and eligibility requirements in ways that are expected to adversely affect health center revenues. Proposed Medicaid funding cuts are expected to lead to reductions in service capacity across all health centers over the long term. State policymakers should understand the likely impacts of proposed Medicaid program changes on health centers in their states and allocate funding to help offset lost federal financing.

CONTEXT

In 2017, Congress considered implementing block grants or per capita caps to significantly reduce federal financing of the Medicaid program. Medicaid plays a key role in supporting health centers in their provision of care to patients with Medicaid coverage. Consequently, changes to the program could have serious implications for health centers and their ability to fulfill their mission.

METHODS

We used a mixed-methods approach to (a) test a model simulating the effect of block grants and per capita caps on health centers' total revenues and general service capacity, and (b) augment model assumptions by using information collected from official Medicaid documents and interviews with health center leadership staff. Data came from the Uniform Data Systems (UDS), state- and county-level population projections, structured analyses of waiver documents, and interviews with health center leaders in seven states with approved or pending Medicaid §1115 waivers.

FINDINGS

By 2024, in states where Medicaid coverage was expanded under the Affordable Care Act, block grant funding for Medicaid would decrease total health center revenues for the expansion population by 92%, and by 58% for traditional enrollees. In nonexpansion states, block grants would decrease health center revenues for traditional Medicaid enrollees by 38%. In expansion states, a per capita cap would, by 2024, decrease health center revenues for the expansion population by 78%, and for traditional Medicaid enrollees by 3%. The per capita cap would reduce health center revenues for traditional Medicaid enrollees in nonexpansion states by 2%. Eliminating the Medicaid expansion population would not fully compensate for health center revenue deficits in expansion states. Health center executives in all sample states expressed significant uncertainty around federal plans to reduce Medicaid funding as well as the financial implications of §1115 waiver requirements. Many interviewees anticipate cutting back on services and/or staff as a result.

CONCLUSIONS

Both block grants and per capita caps would have a detrimental effect on health centers. Although health center leaders anticipate a reduction in services and/or staff, the uncertainty around federal and state proposals hinders health centers from making concrete strategic plans. States should prioritize communicating changes to health centers in a timely manner and be prepared to set aside dedicated funding to address anticipated shortfalls.

Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.

Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions

PURPOSE

The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015).

METHODS

This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model.

RESULTS

Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had ≥1 diagnosed health condition. The adjusted proportion of patients with high use (≥6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P <.001) or gained other insurance (pre-ACA: 29%, post-ACA: 48%, P <.001), whereas the percentage fell slightly for those continuously uninsured.

CONCLUSIONS

A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have ≥3 visits to CHCs. CHCs continue to be essential providers for uninsured patients.

Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review

Community health centers (CHCs) deliver affordable health services to underserved populations, especially uninsured and Medicaid enrollees. Since the early 2000s, CHCs have grown because of federal investments in CHC capacity and expansions of Medicaid eligibility. We review 24 relevant studies from 2000 to 2017 to evaluate the relationship between CHCs, policies that invest in services for low-income individuals, and access to care. Most included studies use quasi-experimental designs. Greater spending on CHCs improves access to care, especially for low-income and minority individuals. Medicaid expansions also increase CHC use. Some studies indicate that CHC investments complement Medicaid expansions to increase access cost-effectively. Further research should explore patient preferences and patterns of CHC utilization versus other sites of care and population subgroups for which expanding CHC capacity improves access to care most. Researchers should endeavor to use measures and sample definitions that facilitate comparisons with other estimates in the literature.

Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type

BACKGROUND

Title X supports access to family planning and preventive care services. Given its focus on low-income clients, Title X clinics may have been particularly affected by the Affordable Care Act's Medicaid expansion.

OBJECTIVES

To examine the impact of the Affordable Care Act's Medicaid expansion on Title X client volumes, health insurance coverage, and contraceptive method mix.

RESEARCH DESIGN

A difference-in-differences design compared changes in the outcomes of interest before and after expansion, for expansion versus nonexpansion states.

SUBJECTS

Administrative data from Family Planning Annual Reports that describe Title X clients who sought services.

MEASURES

Female client volume was measured using a participation ratio defined as the number of female clients per 100 women aged 15-44 with incomes <250% of the federal poverty line. We also examined the share of clients by insurance type and contraceptive method type.

RESULTS

We did not find evidence that expansion was related to changes in client volume. We did find a significant 9.9 percentage point increase in the share of clients with Medicaid and a significant 10.0 percentage point decrease in the share of clients without coverage. We found suggestive evidence that expansion was associated with increased use of long-acting reversible contraceptives, but those results were somewhat sensitive to model specification.

CONCLUSIONS

Expansion was associated with meaningful increases in Medicaid coverage at Title X clinics and declines in uninsurance. Our results have important implications for the financial stability of Title X clinics in light of historical declines in Title X grant revenues.

The Effects of Community Health Center Care on Medical Expenditures for Children and Adults: Propensity Score Analyses

This study examines whether community health center (CHC) patients have lower medical expenditures. Using 2011-2012 Medical Expenditure Panel Survey data, propensity score methods are used to compare annual expenditures for adults and children receiving at least half their ambulatory care at CHCs versus those who did not. For children, CHC use was associated with 35.3% lower total medical expenditures ($627), 40.0% lower ambulatory expenditures ($279), and 49.1% lower prescription drug expenditures ($157) (all Ps < .05). For adults, the reduction in hospital expenditures for CHC users ($529) was statistically significant at a P < .10 threshold. Estimated differences in total expenditures and other expenditure categories were not statistically significant for adults.

Medicaid Expansion And Community Health Centers: Care Quality And Service Use Increased For Rural Patients

Medicaid expansion had great potential to affect community health centers (CHCs), particularly in rural areas, because their patients are predominantly low income and disproportionately uninsured. Using data for 2011-15 on all CHCs, we found that after two years Medicaid expansion was associated with an 11.44-percentage-point decline in the share of CHC patients who were uninsured and a 13.15-percentage-point increase in the share with Medicaid. Changes in quality and volume were consistently observed in rural CHCs in expansion states, which had relative improvements in asthma treatment, body mass index screening and follow-up, and hypertension control, along with substantial increases in volumes for eighteen of twenty-one types of visits-particularly those for mammograms, abnormal breast findings, alcohol-related disorder, and other substance abuse disorder. Similar relative gains were not observed in urban CHCs in expansion states. Repealing or phasing out Medicaid expansion could reverse observed gains in quality and service use and could be particularly detrimental to low-income rural populations.

Oregon's Emphasis On Equity Shows Signs Of Early Success For Black And American Indian Medicaid Enrollees

In 2012 Oregon transformed its Medicaid program, providing coverage through sixteen coordinated care organizations (CCOs). The state identified the elimination of health disparities as a priority for the CCOs, implementing a multipronged approach that included strategic planning, community health workers, and Regional Health Equity Coalitions. We used claims-based measures of utilization, access, and quality to assess baseline disparities and test for changes over time. Prior to the CCO intervention there were significant white-black and white-American Indian/Alaska Native disparities in utilization measures and white-black disparities in quality measures. The CCOs' transformation and implementation of health equity policies was associated with reductions in disparities in primary care visits and white-black differences in access to care, but no change in emergency department use, with higher visit rates persisting among black and American Indian/Alaska Native enrollees, compared to whites. States that encourage payers and systems to prioritize health equity could reduce racial and ethnic disparities for some measures in their Medicaid populations.

Changes in primary care access at community health centers between 2012/2013 and 2016

OBJECTIVE

To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act.

DATA SOURCE

Ten state primary care audit conducted in 2012/2013 and 2016.

STUDY DESIGN

CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type.

PRINCIPAL FINDINGS

In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance.

CONCLUSION

Appointment availability at CHCs improved after ACA implementation, without increased wait times.

The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers

OBJECTIVE

To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion.

METHODS

Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes.

RESULTS

Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states.

CONCLUSION

The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.

Impacts of the Affordable Care Act on Community Health Centers: Characteristics of New Patients and Early Changes in Delivery of Care

The aim of this study was to assess the impact of the Affordable Care Act (ACA) on community health centers (CHCs). Using electronic health records from the Community Health Applied Research Network, we assessed new patient characteristics, office visit volume, and payer distribution among CHC patients before and after ACA implementation, 2011-2014 (n = 442 455). New patients post-ACA were younger, more likely to be female and have chronic health conditions, and utilized more primary care (P < .05 for each). Post-ACA, clinics delivered 19% more office visits and more visits were reimbursed by Medicaid. The support of CHCs is needed to meet increased demand post-ACA.

Growing Insurance Coverage Did Not Reduce Access To Care For The Continuously Insured

Recent expansions in health insurance coverage have raised concerns about health care providers' capacity to supply additional services and how that may have affected access to care for people who were already insured. When we examined data for the period 2008-14 from the Medical Expenditure Panel Survey, we found no consistent evidence that increases in the proportions of adults with insurance at the local-area level affected access to care for adults residing in the same areas who already had, and continued to have, insurance. This lack of an apparent relationship held true across eight measures of access, which included receipt of preventive care. It also held true among two adult subpopulations that may have been at greater risk for compromised access: people residing in health care professional shortage areas and Medicaid beneficiaries.

Navigating payer heterogeneity in the United States: lessons for primary care

With most providers accepting private and public funding, the US exemplifies hybridization, which results in both systemic benefits and harms. While this practice stimulates innovation, encourages practices to be efficient, and increases choice, it has also been linked to gaps in patient safety and overtreatment. We propose three lessons from the US for navigating a public and private system: hybridization allows for innovation; hybridization leads to administrative complexity; and if the costs of participation outweigh the benefits, practices may undergo dehybridization.

There and Back Again: How the Repeal of ACA Can Impact Community Health Centers and the Populations They Serve

We examined the impact of Medicaid expansion on rates of the remaining uninsured at the federally qualified health center level by race/ethnicity, limited English proficiency, and poverty status of their patients. Results indicated a systematic disadvantage in nonexpansion states for federally qualified health centers with high concentrations of these populations and an advantage in expansion states for federally qualified health centers with fewer limited English proficiency patients. Our findings highlight the importance of maintaining the Affordable Care Act in reducing disparities in coverage and the importance of federal funding to continue services for the remaining uninsured and vulnerable populations in both expansion and nonexpansion states.

Trends in Health Insurance Coverage of Title X Family Planning Program Clients, 2005-2015

BACKGROUND

The federal Title X Family Planning Program supports the delivery of family planning services and related preventive care to 4 million individuals annually in the United States. The implementation of the 2010 Affordable Care Act's (ACA's) Medicaid expansion and provisions expanding access to health insurance, which took effect in January 2014, resulted in higher rates of health insurance coverage in the U.S. population; the ACA's impact on individuals served by the Title X program has not yet been evaluated.

METHODS

Using administrative data we examined changes in health insurance coverage among Title X clinic patients during 2005-2015.

RESULTS

We found that the percentage of clients without health insurance decreased from 60% in 2005 to 48% in 2015, with the greatest annual decrease occurring between 2013 and 2014 (63% to 54%). Meanwhile, between 2005 and 2015, the percentage of clients with Medicaid or other public health insurance increased from 20% to 35% and the percentage of clients with private health insurance increased from 8% to 15%.

CONCLUSIONS

Although clients attending Title X clinics remained uninsured at substantially higher rates compared with the national average, the increase in clients with health insurance coverage aligns with the implementation of ACA-related provisions to expand access to affordable health insurance.

Impact of Recent Medicaid Expansions on Office-Based Primary Care and Specialty Care among the Newly Eligible

OBJECTIVE

To quantify the effect of Medicaid expansions on office-based care among the newly eligible.

DATA SOURCE

2008-2014 Medical Expenditure Panel Survey.

STUDY DESIGN

The main sample is adults age 26-64 with incomes ≤138% of poverty who were not eligible for Medicaid prior to the Affordable Care Act. For this population, difference-in-differences linear probability models compare utilization between expansion and nonexpansion states and between 2008-2013 and 2014.

EXTRACTION METHODS

Medicaid eligibility is simulated using data on family relationships, state of residence, and income.

PRINCIPAL FINDINGS

Relative to comparable adults in nonexpansion states, newly eligible adults in expansion states were 9.1 percentage points more likely to have any office-based primary care physician visit in 2014, a 21.4% increase from 2013 (p-value = .004); 6.9 percentage points more likely to have a specialist visit, a 25.2% increase from 2013 (p-value = .036); and 5.1 percentage points more likely to have a visit with a nurse practitioner, nurse, or physician assistant, a 34.5% increase from 2013 (p-value = .016).

CONCLUSIONS

State Medicaid expansions in 2014 were associated with greater likelihoods of visits with a variety of office-based providers. The estimated effects are larger among newly eligible compared with previous estimates on broader populations of low-income adults.