Following Uninsured Patients Through Medicaid Expansion: Ambulatory Care Use and Diagnosed Conditions

Abstract

Purpose: The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015).

Methods: This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model.

Results: Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had ≥1 diagnosed health condition. The adjusted proportion of patients with high use (≥6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P <.001) or gained other insurance (pre-ACA: 29%, post-ACA: 48%, P <.001), whereas the percentage fell slightly for those continuously uninsured.

Conclusions: A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have ≥3 visits to CHCs. CHCs continue to be essential providers for uninsured patients.

Keywords: Medicaid; Patient Protection and Affordable Care Act; access to health care; health care delivery; medically uninsured; preexisting condition; primary health care.

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).

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).

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).