Article Figures & Data
Figures
- Figure 1
Predicted probabilities of categorizing to 1 of 3 post-ACA visit levels (1-2, 3-5, ≥6 overall ambulatory care visits per period) by insurance group and period.
ACA = Patient Protection and Affordable Care Act.
Notes: Pre-ACA = January 1, 2012 to December 31, 2013; Post-ACA = January 1, 2014 to December 31, 2015.
Visits refer to overall ambulatory care use, which includes all billable encounters.
Continuously Uninsured: All preperiod visits were uninsured, and all postperiod visits were uninsured.
Gained Medicaid: All preperiod visits were uninsured, and all postperiod visits were covered by Medicaid with the following exception: to allow for time to enroll in Medicaid, the first visit post-ACA could be uninsured.
Gained Other Insurance: All preperiod visits were uninsured, and during the post-ACA period, visits were covered by other insurance types or insurance patterns (churning).
Pre/post changes in the predicted probabilities were significantly different for each insurance group (P <.05) after adjusting for age, sex, language, race/ethnicity, federal poverty level, clinic location, and Charlson Comorbidity Index score (see Supplemental Appendix 2, http://www.annfammed.org/content/17/4/336/suppl/DC1 for full model results).
Tables
- Table 1
Characteristics of the Community Health Center Patients Who Were Uninsured Before the ACA, Stratified by Insurance Group (N = 138,246)
Continuously Uninsureda (n = 28,834 [20.9%]) Gained Medicaidb (n = 20,766 [15.0%]) Gained Other Insurancec (n = 17,171 [12.4%]) No Post-ACA Period Ambulatory Care Visitsd (n = 71,475 [51.7%]) Sex, No. (%) Female 15,607 (54.1) 10,694 (51.5) 9,958 (58.0) 33,128 (46.3) Male 13,227 (45.9) 10,072 (48.5) 7,213 (42.0) 38,347 (53.7) Age during study period, No. (%), y 19-26 4,890 (17.0) 3,279 (15.8) 2,277 (13.3) 18,301 (25.6) 27-44 15,303 (53.1) 8,232 (39.6) 6,937 (40.4) 32,217 (45.1) 45-64 8,641 (30.0) 9,255 (44.6) 7,957 (46.3) 20,957 (29.3) Race/ethnicity, No. (%) Non-Hispanic white 8,706 (30.2) 10,596 (51.0) 6,984 (40.7) 31,383 (43.9) Hispanic 16,288 (56.5) 5,867 (28.2) 6,808 (39.6) 22,516 (31.5) Non-Hispanic black 2,236 (7.8) 2,693 (13.0) 2,395 (13.9) 10,224 (14.3) Non-Hispanic other 608 (2.1) 918 (4.4) 513 (3.0) 2,637 (3.7) Missing 996 (3.5) 692 (3.3) 471 (2.7) 4,715 (6.6) Preferred language, No. (%) English 14,487 (50.2) 16,710 (80.5) 12,036 (70.1) 54,886 (76.8) Spanish 13,512 (46.9) 3,124 (15.0) 4,653 (27.1) 12,728 (17.8) Other 505 (1.8) 842 (4.1) 399 (2.3) 2,223 (3.1) Missing 330 (1.1) 90 (0.4) 83 (0.5) 1,638 (2.3) Federal poverty level, No. (%) ≤138% 18,780 (65.1) 17,034 (82.0) 10,978 (63.9) 50,761 (71.0) >138% 4,608 (16.0) 2,085 (10.0) 3,861 (22.5) 9,469 (13.2) Missing 5,446 (18.9) 1,647 (7.9) 2,332 (13.6) 11,245 (15.7) Clinic location, No. (%) Rural 1,736 (6.0) 1,983 (9.5) 2,304 (13.4) 6,000 (8.4) Urban 27,098 (94.0) 18,783 (90.5) 14,867 (86.6) 65,475 (91.6) ACA = Patient Protection and Affordable Care Act.
Notes: Pre-ACA = January 1, 2012 to December 31, 2013; Post-ACA = January 1, 2014 to December 31, 2015. Visits refer to ambulatory care only. Pairwise insurance group differences for Continuously Uninsured vs Gained Medicaid, Continuously Uninsured vs Gained Other Insurance, and Continuously Uninsured vs No Post-ACA Period Ambulatory Care Visits were statistically significant (P <.05).
↵a All preperiod visits were uninsured, and all postperiod visits were uninsured.
↵b All preperiod visits were uninsured, and all postperiod visits were covered by Medicaid with the following exception: to allow for time to enroll in Medicaid, the first visit post-ACA could be uninsured.
↵c All preperiod visits were uninsured, and during the post-ACA period, visits were covered by other insurance types or insurance patterns (churning).
↵d All preperiod visits were uninsured, and there were no visits during the post-ACA period.
- Table 2
Pre- and Post-ACA Diagnosed Health Conditions and Clinical Complexity of Community Health Center Patients Who Were Uninsured in the Pre-ACA Period, Stratified by Insurance Group (N = 138,246)
Continuously Uninsureda (n = 28,834) Gained Medicaidb (n = 20,766) Gained Other Insurancec (n = 17,171) No Post-ACA Period Ambulatory Care Visitsd (n = 71,475) Diagnosed health conditions Pre-ACA period ≥1 condition, % of patients 55.5 64.2 61.9 39.9 No. of preperiod diagnoses, mean (SD) 1.4 (1.1) 1.5 (1.2) 1.4 (1.2) 1.5 (1.0) No. of postperiod new diagnoses, mean (SD) 2.0 (1.2) 2.6 (1.6) 2.5 (1.5) … Pre/post change, mean +0.6Ref +1.1e +1.1e … Charlson Comorbidity Index score Pre-ACA period ≥1 score, % of patients 47.3 59.1 58.9 34.3 Pre-ACA period, mean (SD) 1.3 (1.9) 2.1 (2.3) 1.8 (2.2) 1.1 (1.8) Post-ACA period, mean (SD) 1.6 (2.1) 2.9 (2.6) 2.5 (2.6) … Pre/post change, mean +0.3Ref +0.8e +0.7e … ACA = Patient Protection and Affordable Care Act; Ref = reference group.
Notes: Pre-ACA = January 1, 2012 to December 31, 2013; Post-ACA = January 1, 2014 to December 31, 2015. Visits refer to ambulatory care only. Preexisting conditions were identified by International Classification of Diseases, Ninth or Tenth Revision codes on patients’ problem lists or encounter diagnoses. Preexisting conditions included human immunodeficiency virus infection/acquired immune deficiency syndrome; systemic lupus erythematosus; alcohol or drug abuse; mental disorders; Alzheimer’s disease/dementia; multiple sclerosis; rheumatoid arthritis, fibromyalgia, or other inflammatory joint disease; muscular dystrophy; cancer other than skin; severe obesity; cerebral palsy; congestive heart failure; paraplegia or paralysis; coronary artery disease; Crohn’s disease or ulcerative colitis; Parkinson’s disease; chronic obstructive pulmonary disease, emphysema, or asthma; diabetes mellitus; Pneumocystis pneumonia; epilepsy; hemophilia; sleep apnea; hepatitis; stroke; and kidney disease/renal failure. Pairwise insurance-group differences between Continuously Uninsured vs Gained Medicaid, Continuously Uninsured vs Gained Other Insurance, and Continuously Uninsured vs No Post-ACA Period Ambulatory Care Visits were statistically significant (P <.05) for pre-ACA period ≥1 condition/score.
↵a All preperiod visits were uninsured, and all postperiod visits were uninsured.
↵b All preperiod visits were uninsured, and all postperiod visits were covered by Medicaid with the following exception: to allow for time to enroll in Medicaid, the first visit post-ACA could be uninsured.
↵c All preperiod visits were uninsured, and during the post-ACA period, visits were covered by other insurance types or insurance patterns (churning).
↵d All preperiod visits were uninsured, and there were no visits during the post-ACA period.
↵e Statistically significant (P <.05) interaction terms between insurance groups by time period using a Poisson regression model.
- Table 3
Percentage of Ambulatory Primary and Preventive Care Visits Stratified by Insurance Group and ACA Period
Continuously Uninsureda (n = 28,834) Gained Medicaidb (n = 20,766) Gained Other Insurancec (n = 17,171) No Post-ACA Period Ambulatory Care Visitsd (n = 71,475) Overall ambulatory care visit rates per patient per period Pre-ACA period, rate 4.64 4.57 5.47 2.18 Post-ACA period, rate 4.00 6.29 7.59 … Pre/post rate change −0.64Ref 1.72e 2.12e … Overall ambulatory care visits, No. (%) Pre-ACA period 0 … … … … 1-2 12,150 (42.1) 9,579 (46.1) 6,603 (38.5) 54,450 (76.2) 3-5 8,998 (31.2) 6,123 (29.5) 5,030 (29.3) 12,462 (17.4) ≥6 7,686 (26.7) 5,064 (24.4) 5,538 (32.3) 4,563 (6.4) Post-ACA period 0 … … … … 1-2 14,298 (49.6) 7,009 (33.8) 3,177 (18.5) … 3-5 8,195 (28.4) 6,180 (29.8) 5,475 (31.9) … ≥6 6,341 (22.0) 7,577 (36.5) 8,519 (49.6) … Primary care visits, No. (%) Pre-ACA period 0 2,310 (8.0) 901 (4.3) 975 (5.7) 12,631 (17.7) 1-2 12,406 (43.0) 9,681 (46.6) 6,646 (38.7) 45,693 (63.9) 3-5 8,722 (30.2) 6,153 (29.6) 5,232 (30.5) 10,144 (14.2) ≥6 5,396 (18.7) 4,031 (19.4) 4,318 (25.1) 3,007 (4.2) Post-ACA period 0 2,595 (9.0) 462 (2.2) 364 (2.1) … 1-2 14,210 (49.3) 7,297 (35.1) 3,858 (22.5) … 3-5 7,758 (26.9) 6,393 (30.8) 5,989 (34.9) … ≥6 4,271 (14.8) 6,614 (31.9) 6,960 (40.5) … Preventive care visits, No. (%) Pre-ACA period 0 24,228 (84.0) 18,508 (89.1) 14,696 (85.6) 66,499 (93.0) 1-2 4,590 (15.9) 2,254 (10.9) 2,465 (14.4) 4,971 (7.0) 3-5 16 (0.1) 4 (0) 10 (0.1) 5 (0) Post-ACA period 0 24,839 (86.1) 16,942 (81.6) 12,883 (75.0) … 1-2 3,971 (13.8) 3,792 (18.3) 4,232 (24.6) … 3-5 24 (0.1) 32 (0.2) 56 (0.3) … ACA = Patient Protection and Affordable Care Act; Ref = reference group.
Notes: Pre-ACA = January 1, 2012 to December 31, 2013; Post-ACA = January 1, 2014 to December 31, 2015.
Visits refer to ambulatory care only.
Overall ambulatory care use includes all billable encounters. Primary care Current Procedural Terminology codes: 99201-99205, 99212-99215, 99241-99245, 99381-99387, 99391-99397. Preventive care Current Procedural Terminology codes: 99385-99387, 99395-99397.
Pairwise insurance-group differences between Continuously Uninsured vs Gained Medicaid, Continuously Uninsured vs Gained Other Insurance, and Continuously Uninsured vs No Post-ACA Period Ambulatory Care Visits were statistically significant for overall, primary care, and preventive care visits (P <.05).
↵a All preperiod visits were uninsured, and all postperiod visits were uninsured.
↵b All preperiod visits were uninsured, and all postperiod visits were covered by Medicaid with the following exception: to allow for time to enroll in Medicaid, the first visit post-ACA could be uninsured.
↵c All preperiod visits were uninsured, and during the post-ACA period, visits were covered by other insurance types or insurance patterns (churning).
↵d All preperiod visits were uninsured, and there were no visits during the post-ACA period.
↵e Statistically significant (P < .05) interaction terms between insurance groups by time period using a Poisson regression model.
Supplemental Appendixes
Supplemental Appendixes
Files in this Data Supplement:
- Supplemental data: Appendixes - PDF file
The Article in Brief
Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions
Nathalie Huguet , and colleagues
Background The Affordable Care Act improved access to health insurance, yet millions remain uninsured. While many of those uninsured patients receive care from community health centers (CHCs), little is known about their health conditions and utilization. We assessed ambulatory care utilization and diagnosed health conditions among a cohort of CHC patients uninsured pre-ACA and followed them post-ACA.
What This Study Found In community health centers in Medicaid expansion states, among established patients who were uninsured prior to the Affordable Care Act, many remained uninsured after implementation of the Obama-era law. Using electronic health record data across 11 Medicaid expansion states, an Oregon Health & Science University study tracking uninsured patients before and after the implementation of the ACA found that 21% of those patients remained continuously uninsured, 15% gained Medicaid, 12% gained other insurance, and 51% did not visit their Community Health Center post ACA implementation. The 21% who remained uninsured were largely Hispanic and spoke Spanish as their primary language, indicating both a language and potential legal barrier to enrollment in the ACA. These uninsured patients continued to have frequent healthcare visits and the majority had at least one health condition that would require continuous care.
Implications
- The results of this study point to a need for additional funding to support the needs of Community Health Centers serving the uninsured.
