Community Health Center Use After Oregon’s Randomized Medicaid Experiment

Dr DeVoe and colleagues take advantage of a state-sponsored randomized health care experiment to assess the impact of Medicaid expansion on increases in patients seen at federally qualified health centers in Oregon. Their use of rigorous research methods provides convincing evidence that Medicaid expansion in Oregon resulted in more patients with Medicaid being seen by the health centers. The central question is external validity. Do findings from Oregon generalize to other states?

Several lines of evidence support the authors' contention that their findings apply more broadly. First, empirical data from another state showed similar results. After then-governor Mitt Romney signed a state version of the Affordable Care Act into Massachusetts law, enrollments in federally qualified health centers among newly insured patients increased more than 30%.[1] In other words, when formerly uninsured patients had greater options for choice of care, many chose community health centers.

Second, the results are plausible. Most of us make choices based on habit and evaluation of competing options. Many of us could obtain cheaper care insurance with similar coverage but we fail to act. Old patterns of habit die hard. Many patients who have previously obtained care through community health centers when uninsured will continue to do so out of habit.

Furthermore, acquiring insurance through Medicaid does not ensure that primary care practices are accept appointments for new patients much less patient insured through Medicaid. Historically, Medicaid has paid physicians in private practice much less than commercial plans and even less than Medicare. The Affordable Care Act ensured temporary parity in payments between Medicare and Medicaid to primary care physicians for two years. Appointments for new patients with Medicaid improved during this period, but access remained low in many communities.[2] Restricted access to primary care among patients with Medicaid in many communities will mean that community health centers continue to serve as a primary care safety net even for those with health insurance.

Last, based on objective measures, community health centers stack up well against other primary care providers.[3] Community health centers lead other primary care providers in obtaining electronic health records (88%) and patient-centered medical home status (61%) (http://bphc.hrsa.gov/uds/datacenter.aspx). They have consistently achieved comparable if not better health care quality including reductions in avoidable emergency department visits and hospitalizations and patient satisfaction.[4,5] Roll-out of the early community health centers was associated with appreciate reductions in all-cause mortality in surrounding communities.[6] When Massachusetts patients were asked why they choose community health centers, the main reasons were convenience and affordability.[1] Less often patients cited lack of alternatives and language services.[1] In summary, the findings from Drs DeVoe and colleagues' excellent study likely generalize to other states. Within another year or so, I predict that HRSA user data will show that patient enrollments increase with health centers located within states that opted for Medicaid expansion.

1. Ku L, Jones E, Shin P, Byrne FR, Long SK. Safety-net providers after health care reform: lessons from Massachusetts. Arch. Intern. Med. 2011;171(15):1379-1384.
2. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N. Engl. J. Med. Feb 5 2015;372(6):537-545.
3. Shin P, Sharac J, Rosenbaum S. Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation. Health Aff. (Millwood). 2015;34(7):1096-1104.
4. Shi L, Lebrun-Harris LA, Parasuraman SR, Zhu J, Ngo-Metzger Q. The Quality of Primary Care Experienced by Health Center Patients. The Journal of the American Board of Family Medicine. 2013;26(6):768-777.
5. Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing disparities in access to primary care and patient satisfaction with care: the role of health centers. J. Health Care Poor Underserved. 2013;24(1):56-66.
6. Bailey MJ, Goodman-Bacon A. The War on Poverty's experiment in public medicine: Community health centers and the mortality of older Americans. National Bureau of Economic Research; 2014.

Competing interests: None declared