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Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion.

ABSTRACT: The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) providing primary care in medically-underserved communities. However, beyond evidence of initial policy effects, little is understood in the scholarly literature about whether the ACA Medicaid expansion affected longer-lasting changes in CHC patient insurance mix. This study's objective was to examine whether the ACA Medicaid expansion was associated with lasting increases in the annual percentage of adult CHC patients covered by Medicaid and decreases in the annual percentage of uninsured adult CHC patients at expansion-state CHCs, compared to non-expansion-state CHCs. This observational study examined 5353 CHC-year observations from 2012 to 2018 using Uniform Data System data and other national data sources. Using a 2-way fixed-effects multivariable regression approach and marginal analysis, intermediate-term policy effects of the Medicaid expansion on annual CHC patient coverage outcomes were estimated. By 5-years post-expansion, the Medicaid expansion was associated with an overall average increase of 11.7 percentage points in the percentage of adult patients with Medicaid coverage at expansion-state CHCs, compared to non-expansion-state CHCs. Among expansion-state CHCs, 39.8% of adult patients were predicted to have Medicaid coverage 5-years post-expansion, compared to 19.0% of non-expansion-state adult CHC patients. A state's decision to expand Medicaid was similarly associated with decreases in the annual percentage of uninsured adult CHC patients. Primary care operations at CHCs critically depend on patient Medicaid revenue. These findings suggest the ACA Medicaid expansion may provide longer-term financial security for expansion-state CHCs, which maintain increases in Medicaid-covered adult patients even 5-years post-expansion. However, these financial securities may be jeopardized should the ACA be ruled unconstitutional in 2021, a year after CHCs experienced new uncertainties caused by COVID-19.

SUBMITTER: Goldstein EV

PROVIDER: S-EPMC8182175 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceUse of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net.ObjectiveTo evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception).Design, setting, and participantsThis was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states).ExposuresMedicaid expansion status (by state).Main outcomes and measuresTwo National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception).ResultsThe sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states.Conclusions and relevanceIn this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.

Project description:ImportanceTrauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.ObjectiveTo use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.Design, setting, and participantsQuasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states.Interventions/exposurePolicy implementation in January 2014.Main outcomes and measuresChanges in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.ResultsA total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.Conclusions and relevanceThis multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Project description:ImportanceState decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown.ObjectiveTo assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs.Design setting and participantsUsing a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021.ExposuresLocation in a state that expanded Medicaid eligibility as of 2014.Main outcomes and measuresRates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity.ResultsOf the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations.Conclusions and relevanceIn this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic populations. States considering Medicaid expansion may benefit from improved longer-run health measures for underserved patients with chronic conditions.

Project description:ImportancePhysical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care.ObjectiveTo determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates.Design, setting, and participantsThis ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019.ExposuresState-level Medicaid expansion status.Main outcomes and measuresIncidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state.ResultsData were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates.Conclusions and relevanceMedicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.

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Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion.

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