Impacts of the Affordable Care Act on Community Health Centers: Characteristics of New Patients and Early Changes in Delivery of Care

The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California and Texas

BACKGROUND

The Affordable Care Act (ACA) enabled millions of people to gain coverage that was expected to improve access to healthcare services. However, it is unclear the extent of the policy's impact on Federally Qualified Health Centers (FQHC) and the patients they served. This study sought to understand FQHC administrators' views on the ACA's impact on their patient population and organization. It specifically explores FQHC administrators' perspective on 1) patients' experience with gaining coverage 2) their ability to meet patients' healthcare needs.

METHODS

Twenty-two semi-structured interviews were conducted with administrators from FQHCs in urban counties in 2 Medicaid-expanded states (Arizona and California) and 1 non-expanded state (Texas). An inductive thematic analysis approach was used to analyze the interview data.

RESULTS

All FQHC administrators reported uninsured patients were more likely to gain coverage from Medicaid than from private health insurance. Insured patients generally experienced an improvement in accessing healthcare services but depended on their plan's covered services, FQHCs' capacity to meet demand, and specialist providers' willingness to accept their coverage type.

CONCLUSION

Gaining coverage helped improved newly insured patients' access to care, but limitations remained. Additional policies are required to better address the gaps in the depth of covered services in Medicaid and the most affordable PHI plans and capacity of providers to meet demand to ensure beneficiaries can fully access the health care services they need.

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014

BACKGROUND CONTEXT

Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

PURPOSE

To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

OUTCOME MEASURES

Racial disparities in discharge rates before versus after ACA passage.

METHODS

Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

RESULTS

All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

CONCLUSION

Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.

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

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.

The Potential and Realized Impact of the Affordable Care Act on Health Equity

The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion.