Abstract
PURPOSE Health insurance coverage affects a patient’s ability to access optimal care, the percentage of insured patients on a clinic’s panel has an impact on the clinic’s ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.
METHODS We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).
RESULTS After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56–2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73–4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53–2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52–2.78).
CONCLUSION The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
- Patient Protection and Affordable Care Act
- Medicaid
- health policy
- health insurance
- health care disparities
Footnotes
Conflicts of interest: authors report none.
Funding support: This work was supported by the Agency for Healthcare Research and Quality grant number R01HS024270 and by the National Cancer Institute grant numbers R01CA204267 and R01CA181452. This publication was also made possible by Cooperative Agreement Number U18DP006116 jointly funded by the US Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Disease, and Patient-Centered Outcomes Research Institute (PCORI). Accelerating Data Value Across a National Community Health Center Network (ADVANCE) is funded by PCORI and led by the OCHIN Community Health Information Network in partnership with the Health Choice Network, Fenway Health, CareOregon, Kaiser Permanente Center for Health Research, Legacy Health, Oregon Health & Science University, and the Robert Graham Center.
Disclaimer: The views presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies.
Previous presentation: Part of this manuscript was presented at the North American Primary Care Research Group 44th Annual Meeting; November 12–16, 2016; Colorado Springs, Colorado.
Clinical Trials Registration: NCT02657499
- Received for publication December 16, 2016.
- Revision received May 24, 2017.
- Accepted for publication July 3, 2017.
- © 2017 Annals of Family Medicine, Inc.