Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
Research ArticleOriginal Research

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016

Michael E. Johansen and Caroline R. Richardson
The Annals of Family Medicine November 2019, 17 (6) 526-537; DOI: https://doi.org/10.1370/afm.2462
Michael E. Johansen
1Grant Medical Center, OhioHealth, Columbus, Ohio
2Heritage College of Osteopathic Medicine at Ohio University, Dublin, Ohio
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: michael.johansen@ohiohealth.com
Caroline R. Richardson
3Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Additional Files
  • Figure 1a
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1a

    Proportion of overall population without health insurance.

    Panels b-e allocated the population to different categories as noted in each panel. Bars represent 95% CI.

  • Figure 1b
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1b

    Proportion of population without health insurance, by age.

    Panels b-e allocated the population to different categories as noted in each panel. Bars represent 95% CI.

  • Figure 1c
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1c

    Proportion of population without health insurance, by poverty category.

    Panels b-e allocated the population to different categories as noted in each panel. Bars represent 95% CI.

  • Figure 1d
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1d

    Proportion of population without health insurance, by race/ethnicity.

    Panels b-e allocated the population to different categories as noted in each panel. Bars represent 95% CI.

  • Figure 1e
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1e

    Proportion of population without health insurance, by health status.

    Panels b-e allocated the population to different categories as noted in each panel. Bars represent 95% CI.

  • Figure 2
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 2

    Medical ecology framework: 2002-2016.

    Includes all survey respondents along with survey weights during the period 2002-2016. Data points represent the number of individuals with a visit/contact per 1,000 persons per month by year. Bars represent 95% CI.

  • Figure 3a
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3a

    Visit/contact with physician, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3b
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3b

    Visit/contact with primary care physician, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3c
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3c

    Visit/contact with specialty physician, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3d
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3d

    Visit/contact with dental care, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3e
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3e

    Visit/contact with emergency department, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3f
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3f

    Visit/contact with inpatient hospitalization, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 3g
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3g

    Visit/contact with home health professional, by age category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4a
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4a

    Visit/contact with physician, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4b
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4b

    Visit/contact with primary care physician, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4c
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4c

    Visit/contact with specialty physician, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4d
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4d

    Visit/contact with dental professional, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4e
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4e

    Visit/contact with emergency department, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4f
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4f

    Visit/contact with inpatient hospitalization, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

  • Figure 4g
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 4g

    Visit/contact with home health professional, by poverty category: 2002-2016.

    Panels a-g represent a different contact with the medical care system. Bars represent 95% CI.

Tables

  • Figures
  • Additional Files
    • View popup
    Table 1

    Pre- and Post-Affordable Care Act Visit/Contact Rates and Long-Term Trends

    Overall PopulationPre
    (2012-2013)
    Post
    (2014-2015)
    DifferenceP
    Value
    Rate of Change
    (per Year, 2002-2016)
    P
    Value
    Physician187 (179-196)190 (181-199)3 (−2 to 7).24−1.2 (−1.5 to –0.9)<.001
    Primary care physician102 (97-106)103 (98-108)1 (−2 to 4).41−1.2 (−1.4 to –1.0)<.001
    Specialty physician103 (98-109)106 (100-111)2 (−2 to 6).26−0.1 (−0.4 to 0.1).3
    Emergency department15 (15-16)16 (15-17)1 (0-2).040 (0-0.1).46
    Inpatient hospitalization7 (7-8)7 (6-7)0 (−1 to 0).18−0.1 (−0.1 to –0.1)<.001
    Dental67 (64-71)70 (66-74)2 (0-4).035−0.7 (−0.9 to –0.5)<.001
    Home health visit11 (9-12)13 (12-14)2 (1-3).0010.1 (0-0.2).06
    Age Category
    Age <18 Years
    Physician146 (140-151)146 (141-150)0 (−6 to 6).99−0.5 (−0.9 to –0.1).03
    Primary care physician110 (106-114)113 (109-117)3 (−2 to 8).24−0.6 (−1.1 to –0.3).001
    Specialty physician42 (39-45)38 (36-41)−4 (−7 to –1).050.1 (−0.1 to 0.4).31
    Emergency department12 (11-13)12 (11-13)0 (−1 to 1).92−0.1 (−0.2 to 0).03
    Inpatient hospitalization3 (2-3)2 (2-2)−1 (−1 to 0).0020 (−0.1 to 0).05
    Dental82 (78-86)85 (81-89)3 (−2 to 8).22−0.3 (−0.7 to –0.1).16
    Home health visit4 (2-5)4 (3-5)0 (−1 to 1).990.2 (0.1-0.3)<.001
    Age ≥18 & ≤40 Years
    Physician125 (121-129)121 (116-126)−4 (−10 to 2).16−1.1 (−1.5 to –0.7)<.001
    Primary care physician56 (53-58)53 (51-55)−3 (−5 to 0).05−0.6 (−0.8 to –0.4)<.001
    Specialty physician75 (71-78)73 (69-77)−2 (−7 to 3).45−0.5 (−0.9 to –0.2).002
    Emergency department15 (14-16)14 (13-15)−1 (−2 to 0).170 (−0.1 to 0).28
    Inpatient hospitalization6 (5-6)5 (4-5)−1 (−2 to –1)<.001−0.1 (−0.1 to –0.1)<.001
    Dental48 (46-50)49 (47-51)1 (−2 to 3).59−0.8 (−1.0 to –0.6)<.001
    Home health visit2 (2-3)3 (2-4)1 (0-2).120.1 (0.1-0.2).02
    Age >40 & <65 Years
    Physician203 (198-208)208 (203-213)5 (−1 to 12).08−1.4 (−1.9 to –0.9)<.001
    Primary care physician104 (101-107)107 (103-110)3 (−1 to 7).13−1.3 (−1.6 to –1.0)<.001
    Specialty physician119 (115-123)122 (118-126)3 (−3 to 8).34−0.4 (−0.8 to 0).03
    Emergency department15 (14-16)16 (15-17)1 (−1 to 2).230.1 (0.1-0.2).001
    Inpatient hospitalization7 (7-8)7 (6-7)−1 (−1 to 0).11−0.1 (−0.1 to 0).005
    Dental70 (67-73)71 (68-74)1 (−2 to 5).48−1.3 (−1.6 to –1.1)<.001
    Home health visit8 (6-9)10 (8-12)2 (0-4).070.2 (0-0.3).04
    Age ≥65 Years
    Physician364 (352-376)370 (359-381)5 (−10 to 20).49−1.4 (−2.4 to –0.4).005
    Primary care physician185 (178-191)183 (176-190)−2 (−10 to 7).72−3.0 (−3.7 to –2.4)<.001
    Specialty physician235 (224-247)245 (235-255)10 (−4 to 24).161.4 (0.5-2.3).003
    Emergency department21 (20-23)26 (24-28)5 (3-7)<.0010.1 (0-0.3).1
    Inpatient hospitalization16 (14-17)18 (16-20)2 (0-4).04−0.3 (−0.4 to –0.2)<.001
    Dental83 (78-88)89 (84-94)6 (0-11).040.5 (0-1.0).05
    Home health visit44 (38-50)50 (44-56)6 (0-13).070.1 (−0.5 to 0.7).78
    Poverty CategoryPre
    (2012-2013)
    Post
    (2014-2015)
    DifferenceP
    Value
    Rate of Change (per Year, 2002-2016)P
    Value
    ≤200% Poverty Line
    Physician176 (171-181)179 (174-184)3 (−3 to 9).32−0.9 (−1.4 to –0.4)<.001
    Primary care physician103 (99-106)103 (100-107)1 (−3 to 5).73−0.9 (−1.3 to –0.6)<.001
    Specialty physician90 (86-94)92 (88-96)2 (−3 to 6).520 (−0.8 to –0.2).93
    Emergency department22 (21-23)23 (22-25)1 (0-3).060.1 (0-0.2).17
    Inpatient hospitalization9 (9-10)9 (9-10)0 (−1 to 1).89−0.1 (−0.2 to –0.1)<.001
    Dental44 (42-46)45 (43-48)2 (−1 to 4).220.1 (−0.1 to 0.4).22
    Home health visit19 (16-22)24 (22-27)5 (2-8).0010.4 (0.2-0.6).001
    >200% & ≤400% Poverty Line
    Physician176 (170-182)176 (171-181)0 (−7 to 7).97−1.7 (−2.2 to –1.3)<.001
    Primary care physician97 (93-100)98 (95-102)2 (−3 to 6).49−1.4 (−1.7 to –1.2)<.001
    Specialty physician95 (90-100)94 (90-98)−1 (−7 to 5).81−0.5 (−0.8 to –0.2).002
    Emergency department14 (13-15)14 (13-15)0 (−1 to 2).630 (−0.1 to 0.1).96
    Inpatient hospitalization7 (7-8)6 (5-7)−1 (−2 to 0).03−0.1 (−0.1 to 0).001
    Dental64 (61-67)64 (61-67)0 (−4 to 4).88−0.8 (−1.1 to –0.5)<.001
    Home health visit8 (7-10)9 (7-10)1 (−1 to 2).530 (−0.1 to 0.1).65
    >400% Poverty Line
    Physician207 (201-214)210 (203-215)2 (−6 to 10).60−1.1 (−1.5 to –0.6)<.001
    Primary care physician105 (102-109)106 (102-109)1 (−3 to 5).68−1.3 (−1.6 to –1.0)<.001
    Specialty physician123 (117-128)125 (120-130)3 (−4 to 9).450.1 (−0.3 to 0.4).75
    Emergency department10 (10-11)12 (11-12)1 (0-2).020 (−0.1 to 0).21
    Inpatient hospitalization6 (5-6)5 (5-6)0 (−1 to 1).86−0.1 (−0.1 to –0.1)<.001
    Dental92 (89-96)95 (91-98)2 (−2 to –6).28−1.2 (−1.5 to –0.9)<.001
    Home health visit5 (4-6)6 (5-7)1 (0-3).06−0.1 (−0.2 to 0).02
    • The pre- and post-Affordable Care Act numbers are numbers of individuals per 1,000 per month who reported contact with a type of care. The difference is the change in individuals per 1,000 per month between the pre- and post-ACA periods. The P value was obtained using adjusted Wald tests. The rate of change numbers represent the trends that were inclusive of the entire study period (2002-2016). The numbers represent the change in the number of individuals per 1,000 per month per year that had contact with a service. These trends were obtained using multivariable linear regression models that included, as appropriate, age, age2, and sex as covariates. The inclusion of age and age2 resulted in larger decreases (among nearly all categories) than when excluded in the models. Numbers in parentheses are 95% CIs.

    • Rate of change values for Overall Population and Poverty Category sections adjusted for age, age2, and sex.

    • Rate of change values for Age Category section adjusted for sex.

Additional Files

  • Figures
  • Tables
  • Supplemental Appendixes

    Supplemental Appendixes

    Files in this Data Supplement:

    • Supplemental data: Appendixes - PDF file
  • The Article in Brief

    The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002-2016

    Michael E. Johansen , and colleagues

    Background At the same time the Affordable Care Act increased the number of insured Americans, analysis of health care industry data shows a continued decline in contact with primary care physician services.

    What This Study Found The study applied an "ecology of medical care" framework analysis to a national dataset of Americans' contact with the US medical care system. Tracked services included visits and calls to physicians, including primary care and subspecialty physicians, emergency departments, inpatient hospitalizations, dental visits and home health visits. Analysis showed a drop in the uninsured rate post-Affordable Care Act, from 12.8% in 2013 to 7.6% in 2016. Between 2002 and 2016, patients were overall less likely to see a primary care physician, be hospitalized, or receive dental care. However, contact with home health visits increased.

    Implications

    • Despite the increase in insurance coverage, the Affordable Care Act appeared to have had minimal effect on the trend of decreasing primary care contact in the general population during the first two years after implementation.
PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 17 (6)
The Annals of Family Medicine: 17 (6)
Vol. 17, Issue 6
November/December 2019
  • Table of Contents
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
8 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016
Michael E. Johansen, Caroline R. Richardson
The Annals of Family Medicine Nov 2019, 17 (6) 526-537; DOI: 10.1370/afm.2462

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016
Michael E. Johansen, Caroline R. Richardson
The Annals of Family Medicine Nov 2019, 17 (6) 526-537; DOI: 10.1370/afm.2462
Reddit logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • LIMITATIONS
    • CONCLUSION
    • Acknowledgment
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017
  • Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017
  • Changes in Rates and Content of Primary Care Visits Within an Evolving Health Care System
  • Google Scholar

More in this TOC Section

  • Investigating Patient Experience, Satisfaction, and Trust in an Integrated Virtual Care (IVC) Model: A Cross-Sectional Survey
  • Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations
  • Evaluation of the Oral Health Knowledge Network’s Impact on Pediatric Clinicians and Patient Care
Show more ORIGINAL RESEARCH

Similar Articles

Subjects

  • Person groups:
    • Community / population health
  • Methods:
    • Quantitative methods
  • Other research types:
    • Health policy
    • Health services
  • Core values of primary care:
    • Access
    • Continuity
    • Coordination / integration of care

Keywords

  • health services research
  • delivery of health care
  • primary care
  • health policy

Content

  • Current Issue
  • Past Issues
  • Past Issues in Brief
  • Multimedia
  • Articles by Type
  • Articles by Subject
  • Multimedia
  • Supplements
  • Online First
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Media
  • Job Seekers

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2023 Annals of Family Medicine