An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

Heather Angier; Megan Hoopes; Rachel Gold; Steffani R. Bailey; Erika K. Cottrell; John Heintzman; Miguel Marino; Jennifer E. DeVoe

doi:10.1370/afm.1741

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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.
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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.

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Table 1

Characteristics of States, CHCs, and Encounter Rates Before and After Medicaid Expansion

	Expansion States⁸						Nonexpansion States⁸

Characteristic	CA	MN	OH	OR	WA	Total	AK	IN	MT	NC	Total
State-level factors
Adult Medicaid eligibility,^a pre-²²/post-⁸ expansion period, % of FPL	106/138	215/205	96/138	39/138	71/138	–	78/128	24/24	54/54	47/45	–
Minimum wage, 2014,¹⁹ $/hr	8.00	7.25	7.95	9.10	9.32	–	7.50	7.25	7.90	7.25	–
Unemployment rate, 2014,²⁰ %	7.6	4.6	5.5	6.9	6.1	–	6.4	5.7	4.6	6.4	–
Adult uninsured rate, 2013,²¹ %	21.6	9.5	13.9	19.4	16.8	–	18.9	15.3	20.7	20.4	–
Insurance marketplace²³	State	State	Federal	State^b	State	–	Federal	Federal	Federal	Federal	–
OCHIN CHC characteristics
Primary care CHCs, No.	29	4	14	85	5	137	1	9	5	4	19
Total patients, 2013–June 2014, No.	91,282	7,912	30,422	156,440	14,571	300,356^c	2,198	10,244	9,014	11,861	33,315^c
Female sex, No. (%)	54,890(60.1)	4,477 (56.6)	18,045 (59.3)	93,620 (59.8)	8,819 (60.5)	179,675 (59.8)^d	1,221 (55.6)	6,700 (65.4)	5,265 (58.4)	7,004 (59.1)	20,188 (60.6)
Age-group, as of last visit, No. (%)
19 to 25 y	12,356 (13.5)	1,318 (16.7)	5,466 (18.0)	23,078 (14.8)	2,202 (15.1)	44,386 (14.8)^d	347 (15.8)	1,469 (14.3)	1,876 (20.8)	1,269 (10.7)	4,961 (14.9)
26 to 39 y	29,037 (31.8)	2,920 (36.9)	10,052 (33.0)	52,389 (33.5)	4,696 (32.2)	99,000 (33.0)	760 (34.6)	3,091 (30.2)	2,569 (28.5)	2,683 (22.6)	9,102 (27.3)
40 to 64 y	49,889 (54.7)	3,674 (46.4)	14,904 (49.0)	80,973 (51.8)	7,673 (52.7)	156,970 (52.3)	1,091 (49.6)	5,684 (55.5)	4,569 (50.7)	7,909 (66.7)	19,252 (57.8)
Household income, No. (%)
≤138 % of FPL	60,107 (65.8)	5,415 (68.4)	24,214 (79.6)	114,117 (72.9)	11,338 (77.8)	214,958 (71.6)^d	718 (32.7)	7,507 (73.3)	5,431 (60.3)	5,410 (45.6)	19,066 (57.2)
>138 % of FPL	11,416 (12.5)	523 (6.6)	2,962 (9.7)	24,645 (15.8)	3,118 (21.4)	42,628 (14.2)	1,016 (46.2)	1,038 (10.1)	2,181 (24.2)	2,822 (23.8)	7,055 (21.2)
Missing/unknown	19,759 (21.6)	1,974 (24.9)	3,246 (10.7)	17,678 (11.3)	115 (0.8)	42,770 (14.2)	464 (21.1)	1,699 (16.6)	1,402 (15.6)	3,629 (30.6)	7,194 (21.6)
Nonwhite race, No. (%)	7,914 (8.7)	6,191 (78.2)	15,365 (50.5)	14,709 (9.4)	1,033 (7.1)	45,192 (15.0)^d	647 (29.4)	5,704 (55.7)	332 (3.7)	6,783 (57.2)	13,466 (40.4)
Hispanic ethnicity, No. (%)	41,999 (46.0)	125 (1.6)	4,331 (14.2)	38,243 (24.4)	1,472 (10.1)	86,145 (28.7)^d	227 (10.3)	1,041 (10.2)	336 (3.7)	491 (4.1)	2,095 (6.3)
Urban residence, No. (%)	88,368 (96.8)	7,841 (99.1)	30,410(100.0)	147,320(94.2)	13,518 (92.8)	287,204 (95.6)^d	2,172 (98.8)	10,195 (99.5)	8,083 (89.7)	8,886 (74.9)	29,335 (88.1)
Adjusted^e visit RRs, postexpansion period vs preexpansion period^f
Total visits, RR (95% CI)	0.99 (0.93–1.05)	1.05 (1.03–1.08)^g	1.02 (0.94–1.10)	1.07 (1.03–1.11)^g	1.34 (1.00–1.79)	1.05 (1.01–1.08)^g	0.94^h	0.99 (0.76–1.28)	0.94 (0.85–1.05)	0.93 (0.80–1.08)	0.95 (0.87–1.04)
Uninsured visits, RR (95% CI)	0.92 (0.78–1.09)	0.75 (0.65–0.87)^g	0.82 (0.71–0.94)^g	0.51 (0.45–0.59)^g	0.64 (0.54–0.75)^g	0.60 (0.54–0.67)^g	0.84^h	0.88 (0.68–1.14)	0.83 (0.78–0.88)^g	0.78 (0.57–1.07)	0.84 (0.74–0.95)^g
Medicaid visits, RR (95% CI)	1.03 (0.94–1.12)	1.11 (1.03–1.19)^g	1.17 (1.07–1.29)^g	1.78 (1.60–1.98)^g	2.04 (1.39–2.99)^g	1.36 (1.24–1.49)^g	1.07^h	1.18 (0.86–1.62)	1.03 (1.00–1.07)	0.96 (0.81–1.12)	1.05 (0.94–1.18)
Commercially insured visits, RR (95% CI)	1.08 (0.92–1.27)	0.99 (0.90–1.09)	1.22 (1.09–1.37)^g	0.96 (0.89–1.05)	1.03 (0.84–1.27)	1.02 (0.94–1.09)	0.96^h	1.20 (0.89–1.61)	1.01 (0.82–1.24)	1.03 (0.99–1.06)	1.03 (0.96–1.11)

AK= Alaska; CA = California; CHC = community health center; FPL = federal poverty level; GEE = generalized estimating equation; IN = Indiana; MN = Minnesota; MT= Montana; NC = North Carolina; OCHIN = formerly the Oregon Community Health Information Network; OH = Ohio; OR= Oregon; RR = rate ratio; WA = Washington.
↵a Eligibility FPL levels may differ between adults with children and without, or those who are working and those who are jobless. The number reported indicates the highest FPL limit for open full Medicaid coverage in a given state among these categories.
↵b Because of problems with its state exchange rollout, Oregon opted to switch to the federal exchange in mid-2014.
↵c Expansion group numbers may not sum because an individual patient can have visits in more than 1 state.
↵d Overall percentage differs significantly between expansion states and nonexpansion states by χ² test (P < .001).
↵e Rates by state: Poisson GEE model adjusted for CHC-level factors (percent female, percent younger than age 40 years, percent nonwhite, percent Hispanic, percent ≤138% FPL, percent with unknown FPL, percent urban). Rates by expansion status: Poisson GEE model adjusted for all CHC-level factors plus state-level factors (2014 minimum wage, 2014 unemployment rate, 2013 adult uninsurance rate). All GEE models accounted for temporal correlation over time within CHCs.
↵f Preexpansion period: January 1, 2013, to December 31, 2013; postexpansion period: January 1, 2014, to June 30, 2014.
↵g RR is significantly different from 1.0.
↵h CI cannot be computed because Alaska had only 1 CHC in the sample.

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The Article in Brief

An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

Heather Angier , and colleagues

Background The Affordable Care Act supports significant expansions in Medicaid coverage in the United States. This study explores the number of patient visits to uninsured safety net clinics in states that implemented Medicaid expansion compared with states that did not expand Medicaid.

What This Study Found Medicaid expansions appear to have successfully decreased the number of uninsured safety net patients in the US. Community health centers in states that expanded Medicaid had a 40 percent decrease in the rate of uninsured visits and a 36 percent increase in the rate of Medicaid-covered visits. In contrast, clinics in non-expansion states had a 16 percent decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits.

Implications

This study confirms other reports showing increased health insurance coverage rates following state Medicaid expansion and adds new information demonstrating a measurable effect on community health center visits in Medicaid expansion states.