Impacts of the Affordable Care Act on Receipt of Women's Preventive Services in Community Health Centers in Medicaid Expansion and Nonexpansion States

Womens Health Issues. Jan-Feb 2021;31(1):9-16. doi: 10.1016/j.whi.2020.08.011. Epub 2020 Oct 3.


Background: The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers.

Methods: Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid.

Results: Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51-2.60; and 1.98; 95% confidence interval, 0.91-3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: -4.21; 95% confidence interval, -6.98 to -1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states.

Conclusions: Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Child
  • Community Health Centers
  • Early Detection of Cancer
  • Female
  • Health Services Accessibility
  • Humans
  • Insurance Coverage
  • Medicaid
  • Middle Aged
  • Patient Protection and Affordable Care Act*
  • Preventive Health Services
  • United States
  • Uterine Cervical Neoplasms* / prevention & control
  • Young Adult