An early look at rates of uninsured safety net clinic visits after the Affordable Care Act

Abstract

Purpose: The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not.

Methods: We undertook a longitudinal observational study of coverage status for adult visits in community health centers, from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through 6 months after expansion (January 1, 2014 to June 30, 2014). We analyzed data from 156 clinics in the OCHIN practice-based research network, with a shared electronic health record, located in 9 states (5 expanded Medicaid coverage and 4 did not).

Results: Analyses were based on 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters. Overall, clinics in the expansion states had a 40% decrease in the rate of uninsured visits in the postexpansion period and a 36% increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16% decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits.

Conclusions: There was a substantial decrease in uninsured community health center visits and a significant increase in Medicaid-covered visits in study clinics in states that expanded Medicaid in 2014, whereas study clinics in states opting out of the expansion continued to have a high rate of uninsured visits. These findings suggest that Affordable Care Act-related Medicaid expansions have successfully decreased the number of uninsured safety net patients in the United States.

Keywords: Affordable Care Act; practice-based research; primary care; safety net clinics; uninsured.

Figure 1

Adjusted rates of uninsured visits by month among CHCs in expansion and nonexpansion states. ACA = Affordable Care Act; CHC = community health center. Notes: Rates calculated per 1,000 adult patients across entire study period. Poisson general estimating equation (GEE) model adjusted for percent of patients aged younger than 40 years and percent Hispanic, accounting for temporal correlation within CHCs over time.

Figure 1

Adjusted rates of uninsured visits by month among CHCs in expansion and nonexpansion states. ACA = Affordable Care Act; CHC = community health center. Notes: Rates calculated per 1,000 adult patients across entire study period. Poisson general estimating equation (GEE) model adjusted for percent of patients aged younger than 40 years and percent Hispanic, accounting for temporal correlation within CHCs over time.

Figure 2

Adjusted visit rates by coverage status and month among CHCs in expansion and nonexpansion states. ACA = Affordable Care Act; CHC = community health center. Notes: Rates calculated per 1,000 adult patients across entire study period. Poisson general estimating equation (GEE) model adjusted for percent nonwhite race, percent Hispanic, percent ≤138% federal poverty level (FPL), and percent with unknown FPL; models account for temporal correlation within CHCs over time.