Churning out of insurance among patients with diabetes served in US Community Health Centers

Context: Millions of American are churning out of Medicaid coverage following unwinding of continuous enrollment as a results of the end of the public health emergency. Health insurance instability may be particularly challenging for patients with diabetes who need regular chronic care management to reduce the risk of diabetes complications.

Objective: To evaluate insurance instability (churn) among adults with diabetes receiving care at community-based health centers (CHC) serving socioeconomically disadvantaged patients.

Study Design: Retrospective observational cohort study.

Setting or Dataset: Electronic health records data: 335 CHC from the ADVANCE research Network

Population Studied: Adults (n=309,074) aged 19-64 patients with a baseline insured visit between 2014 and 2019 and at least 3 ambulatory visits over the subsequent 3-year period and at least 12 months separating the first and last visits. 46,844 patients were diagnosed with diabetes during study period.

Outcome Measures: Churning was defined as having two or more consecutive uninsured visits after the baseline insured visit. We compared the odds of churning among patients with versus without diabetes and the factors associated with churning among patients with diabetes using covariate-adjusted generalized estimating equation-based (GEE) logistic regression model.

Results: Patients with diabetes had greater odds of churning (Adjusted Odds Ratio [aOR]= 1.24; 95%CI=1.17, 1.31) than patients without diabetes. Among our patients with diabetes who lost Medicaid coverage, 56% became uninsured and 44% switched to private insurance. Among patients with diabetes, those who were female, aged 19-44, non-Hispanic Black, and Hispanic had higher odds of churning than their counterparts. Patients with out-of-control diabetes had a 32% (aOR=1.32; 95%CI=1.24, 1.41) greater likelihood of churning. Those with more complex diabetes medication regimens (aOR=1.41; 95%CI=1.27, 1.57) and with an acute diabetes complication (aOR=1.19; 95%CI=1.08, 1.32) had higher odds of churning. Having a prescription of insulin was not associated with likelihood of churning.

Conclusions: Our findings suggest that patients with diabetes, especially those with poorer diabetes management, are more likely to experience insurance instability than those without diabetes. State efforts should focus on outreach and assistance to facilitate marketplace insurance enrollment and not exclusively on Medicaid re-enrollment.