1
|
Huguet N, Hodes T, Liu S, Marino M, Schmidt TD, Voss RW, Peak KD, Quiñones AR. Impact of Health Insurance Patterns on Chronic Health Conditions Among Older Patients. J Am Board Fam Med 2023; 36:839-850. [PMID: 37704394 PMCID: PMC10662026 DOI: 10.3122/jabfm.2023.230106r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Patients have varying levels of chronic conditions and health insurance patterns as they become Medicare age-eligible. Understanding these dynamics will inform policies and reforms that direct capacity and resources for primary care clinics to care for these aging patients. This study 1) determined changes in chronic condition rates following Medicare age eligibility among patients with different insurance patterns and 2) estimated the number of chronically ill patients who remain inadequately insured post-Medicare eligibility among patients receiving care in community health centers. METHOD We used retrospective electronic health record data from 45,527 patients aged 62 to 68 from 990 community health centers in 25 states in 2014 to 2019. Insurance patterns (continuously insured, continuously uninsured, uninsured/discontinuously insured who gained insurance after age 65, lost insurance after age 65, discontinuously insured) and diagnosis of chronic conditions were defined at each visit pre- and post-Medicare eligibility. Difference-in-differences Poisson GEE models estimated changes of chronic condition rates by insurance groups pre- to post-Medicare age eligibility. RESULTS Post-Medicare eligibility, 72% patients were continuously insured, 14% gained insurance; and 14% were uninsured or discontinuously insured. The prevalence of multimorbidity (≥2 chronic conditions) was 77%. Those who gained insurance had a significantly larger increase in the rate of documented chronic conditions from pre- to post-Medicare (DID: 1.06, 95%CI:1.05-1.07) compared with the continuously insured group. CONCLUSIONS Post-Medicare age eligibility, a significant proportion of patients were diagnosed with new conditions leading to high burden of disease. One in 4 older adults continue to have inadequate health care coverage in their older age.
Collapse
Affiliation(s)
- Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Tahlia Hodes
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Shuling Liu
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | | | | | - Katherine D. Peak
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Ana R. Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| |
Collapse
|
2
|
Luo Q, Moghtaderi A, Markus A, Dor A. Financial impacts of the Medicaid expansion on community health centers. Health Serv Res 2021; 57:634-643. [PMID: 34658030 DOI: 10.1111/1475-6773.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. DATA SOURCES We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county-level characteristics from the Census Bureau. Our final dataset included 5841 center-year observations. STUDY DESIGN We used difference-in-differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state-specific trend models, and placebo law tests as robustness checks. DATA COLLECTION METHODS Not applicable. PRINCIPAL FINDINGS On the revenue side, we found a $2.08 million relative increase (p = 0.002) in Medicaid revenues, offset by a $0.44 million decrease (p = 0.015) in total grants among community health centers in expansion states compared with centers in non-expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p = 0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p < 0.001) relative to their counterparts in non-expansion states. CONCLUSIONS Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. While Medicaid revenue increased as a result of the policy, we find no major evidence of substitution away from other revenue lines, with one notable exception (i.e., substitution away from state and local government grants). From a policy perspective, these results are encouraging as the Biden Administration starts to implement the safety-net enhancements from the American Rescue Plan Act of 2021 and as more non-expansion states are considering opting into Medicaid expansions. It is anticipated that these added revenue streams will help to sustain health centers in the delivery of health care services to the underserved population.
Collapse
Affiliation(s)
- Qian Luo
- Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA.,Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Ali Moghtaderi
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Anne Markus
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Avi Dor
- Department of Health Policy and Management, Milken Institute of Public Health, The George Washington University, Washington, District of Columbia, USA
| |
Collapse
|
3
|
Lindner S, Levy A, Horner-Johnson W. The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon. Disabil Health J 2020; 14:101010. [PMID: 33419718 DOI: 10.1016/j.dhjo.2020.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/02/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion. OBJECTIVE To examine the association of the ACA expansion on health care access and utilization for adults ages 18-64 years who have qualified for Supplemental Security Income (SSI) in Oregon. METHODS We used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits. RESULTS The Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon's counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association. CONCLUSIONS We did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.
Collapse
Affiliation(s)
- Stephan Lindner
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA; OHSU-PSU School of Public Health, Portland 97239, OR, USA.
| | - Anna Levy
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA
| | - Willi Horner-Johnson
- OHSU-PSU School of Public Health, Portland 97239, OR, USA; OHSU Institute on Development and Disability, Department of Pediatrics, School of Medicine, Portland, 97239, OR, USA
| |
Collapse
|
4
|
Marino M, Angier H, Springer R, Valenzuela S, Hoopes M, O'Malley J, Suchocki A, Heintzman J, DeVoe J, Huguet N. The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers. Diabetes Care 2020; 43:2074-2081. [PMID: 32611609 PMCID: PMC7440906 DOI: 10.2337/dc19-1571] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.
Collapse
Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR .,Biostatistics Group, Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| |
Collapse
|
5
|
Changes in Insurance Coverage and Healthcare Use Among Immigrants and US-Born Adults Following the Affordable Care Act. J Racial Ethn Health Disparities 2020; 8:363-374. [DOI: 10.1007/s40615-020-00790-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 12/29/2022]
|
6
|
Marino M, Angier H, Fankhauser K, Valenzuela S, Hoopes M, Heintzman J, DeVoe J, Moreno L, Huguet N. Disparities in Biomarkers for Patients With Diabetes After the Affordable Care Act. Med Care 2020; 58 Suppl 6 Suppl 1:S31-S39. [PMID: 32412951 PMCID: PMC7365657 DOI: 10.1097/mlr.0000000000001257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial and ethnic minorities are disproportionately affected by diabetes and at greater risk of experiencing poor diabetes-related outcomes compared with non-Hispanic whites. The Affordable Care Act (ACA) was implemented to increase health insurance coverage and reduce health disparities. OBJECTIVE Assess changes in diabetes-associated biomarkers [hemoglobin A1c (HbA1c) and low-density lipoprotein] 24 months pre-ACA to 24 months post-ACA Medicaid expansion by race/ethnicity and insurance group. RESEARCH DESIGN Retrospective cohort study of community health center (CHC) patients. SUBJECTS Patients aged 19-64 with diabetes living in 1 of 10 Medicaid expansion states with ≥1 CHC visit and ≥1 HbA1c measurement in both the pre-ACA and the post-ACA time periods (N=13,342). METHODS Linear mixed effects and Cox regression modeled outcome measures. RESULTS Overall, 33.5% of patients were non-Hispanic white, 51.2% Hispanic, and 15.3% non-Hispanic black. Newly insured Hispanics and non-Hispanic whites post-ACA exhibited modest reductions in HbA1c levels, similar benefit was not observed among non-Hispanic black patients. The largest reduction was among newly insured Hispanics versus newly insured non-Hispanic whites (P<0.05). For the subset of patients who had uncontrolled HbA1c (HbA1c≥9%) within 3 months of the ACA Medicaid expansion, non-Hispanic black patients who were newly insured gained the highest rate of controlled HbA1c (hazard ratio=2.27; 95% confidence interval, 1.10-4.66) relative to the continuously insured group. CONCLUSIONS The impact of the ACA Medicaid expansion on health disparities is multifaceted and may differ across racial/ethnic groups. This study highlights the importance of CHCs for the health of minority populations.
Collapse
Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
- School of Public Health, Oregon Health & Science University—Portland State University
| | - Heather Angier
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
| | - Katie Fankhauser
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
| | - Steele Valenzuela
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
| | | | - John Heintzman
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
- OCHIN, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
- OCHIN, Portland, OR
| | - Laura Moreno
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
| | - Nathalie Huguet
- Department of Family Medicine, Division of Biostatistics, Oregon Health & Science University
| |
Collapse
|
7
|
Saloner B, Wilk AS, Levin J. Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review. Med Care Res Rev 2019; 77:3-18. [DOI: 10.1177/1077558719848283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community health centers (CHCs) deliver affordable health services to underserved populations, especially uninsured and Medicaid enrollees. Since the early 2000s, CHCs have grown because of federal investments in CHC capacity and expansions of Medicaid eligibility. We review 24 relevant studies from 2000 to 2017 to evaluate the relationship between CHCs, policies that invest in services for low-income individuals, and access to care. Most included studies use quasi-experimental designs. Greater spending on CHCs improves access to care, especially for low-income and minority individuals. Medicaid expansions also increase CHC use. Some studies indicate that CHC investments complement Medicaid expansions to increase access cost-effectively. Further research should explore patient preferences and patterns of CHC utilization versus other sites of care and population subgroups for which expanding CHC capacity improves access to care most. Researchers should endeavor to use measures and sample definitions that facilitate comparisons with other estimates in the literature.
Collapse
Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam S. Wilk
- Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathan Levin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
8
|
Guo L, Bao Y, Ma J, Li S, Cai Y, Sun W, Liu Q. Quality of community basic medical service utilization in urban and suburban areas in Shanghai from 2009 to 2014. PLoS One 2018; 13:e0195987. [PMID: 29791470 PMCID: PMC5965823 DOI: 10.1371/journal.pone.0195987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/20/2018] [Indexed: 11/18/2022] Open
Abstract
Urban areas usually display better health care services than rural areas, but data about suburban areas in China are lacking. Hence, this cross-sectional study compared the utilization of community basic medical services in Shanghai urban and suburban areas between 2009 and 2014. These data were used to improve the efficiency of community health service utilization and to provide a reference for solving the main health problems of the residents in urban and suburban areas of Shanghai. Using a two-stage random sampling method, questionnaires were completed by 73 community health service centers that were randomly selected from six districts that were also randomly selected from 17 counties in Shanghai. Descriptive statistics, principal component analysis, and forecast analysis were used to complete a gap analysis of basic health services utilization quality between urban and suburban areas. During the 6-year study period, there was an increasing trend toward greater efficiency of basic medical service provision, benefits of basic medical service provision, effectiveness of common chronic disease management, overall satisfaction of community residents, and two-way referral effects. In addition to the implementation effect of hypertension management and two-way referral, the remaining indicators showed a superior effect in urban areas compared with the suburbs (P<0.001). In addition, among the seven principal components, four principal component scores were better in urban areas than in suburban areas (P = <0.001, 0.004, 0.036, and 0.022). The urban comprehensive score also exceeded that of the suburbs (P<0.001). In summary, over the 6-year period, there was a rapidly increasing trend in basic medical service utilization. Comprehensive satisfaction clearly improved as well. Nevertheless, there was an imbalance in health service utilization between urban and suburban areas. There is a need for the health administrative department to address this imbalance between urban and suburban institutions and to provide the required support to underdeveloped areas to improve resident satisfaction.
Collapse
Affiliation(s)
- Lijun Guo
- Shanghai University of Medicine & Health Sciences, College of Health Information Technology and Management, Pudong New District, Shanghai, China
| | - Yong Bao
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
- Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Changning District, Shanghai, China
- * E-mail:
| | - Jun Ma
- Shanghai Tongren Hospital, Changning District, Shanghai, China
| | - Shujun Li
- Zhengzhou Fifteenth People’s Hospital, Shangjie District, Zhengzhou City, Henan Province, China
| | - Yuyang Cai
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Wei Sun
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Qiaohong Liu
- Shanghai University of Medicine & Health Sciences, College of Health Information Technology and Management, Pudong New District, Shanghai, China
| |
Collapse
|
9
|
Impacts of the Affordable Care Act on Community Health Centers: Characteristics of New Patients and Early Changes in Delivery of Care. J Ambul Care Manage 2018; 41:250-261. [PMID: 29771741 DOI: 10.1097/jac.0000000000000244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to assess the impact of the Affordable Care Act (ACA) on community health centers (CHCs). Using electronic health records from the Community Health Applied Research Network, we assessed new patient characteristics, office visit volume, and payer distribution among CHC patients before and after ACA implementation, 2011-2014 (n = 442 455). New patients post-ACA were younger, more likely to be female and have chronic health conditions, and utilized more primary care (P < .05 for each). Post-ACA, clinics delivered 19% more office visits and more visits were reimbursed by Medicaid. The support of CHCs is needed to meet increased demand post-ACA.
Collapse
|
10
|
Han X, Luo Q, Ku L. Medicaid Expansion And Grant Funding Increases Helped Improve Community Health Center Capacity. Health Aff (Millwood) 2018; 36:49-56. [PMID: 28069846 DOI: 10.1377/hlthaff.2016.0929] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Through the expansion of Medicaid eligibility and increases in core federal grant funding, the Affordable Care Act (ACA) sought to increase the capacity of community health centers to provide primary care to low-income populations. We examined the effects of the ACA Medicaid expansion and changes in federal grant levels on the centers' numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015. In the period after expansion (2014-15), health centers in expansion states had a 5 percent higher total patient volume, larger shares of Medicaid patients, smaller shares of uninsured patients, and increases in overall visits and mental health visits, compared to centers in nonexpansion states. Increases in federal grant funding levels were associated with increases in numbers of patients and of overall, medical, and preventive service visits. If federal grant levels are not sustained after 2017, there could be marked reductions in health center capacity in both expansion and nonexpansion states.
Collapse
Affiliation(s)
- Xinxin Han
- Xinxin Han is a graduate research assistant in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University, in Washington, D.C
| | - Qian Luo
- Qian Luo is a research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, at George Washington University
| | - Leighton Ku
- Leighton Ku is a professor in the Department of Health Policy and Management, Milken Institute School of Public Health, and director of the Center for Health Policy Research, both at George Washington University
| |
Collapse
|
11
|
Hatch B, Marino M, Killerby M, Angier H, Hoopes M, Bailey SR, Heintzman J, O'Malley JP, DeVoe JE. Medicaid's Impact on Chronic Disease Biomarkers: A Cohort Study of Community Health Center Patients. J Gen Intern Med 2017; 32:940-947. [PMID: 28374214 PMCID: PMC5515790 DOI: 10.1007/s11606-017-4051-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/05/2016] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes. OBJECTIVE To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008-2011). DESIGN Prospective cohort. Patients were followed for 24 months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models. SETTING/PATIENTS Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546). MAIN MEASURES Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort. KEY RESULTS All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p < 0.001, respectively). No significant difference was observed in the hyperlipidemia cohort (HR = 1.09, p = 0.392). CONCLUSIONS OCHIN patients with uncontrolled chronic conditions experienced objective health improvements over time. In two of three chronic disease cohorts, those who gained Medicaid coverage were more likely to achieve a controlled measurement than those who remained uninsured. These findings demonstrate the effective care provided by CHCs and the importance of health insurance coverage within a usual source of care setting. CLINICAL TRIALS REGISTRATION NCT02355132 [ https://clinicaltrials.gov/ct2/show/NCT02355132 ].
Collapse
Affiliation(s)
- Brigit Hatch
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
| | - Miguel Marino
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | | | | | | | - Jennifer E DeVoe
- Oregon Health & Science University, Portland, OR, USA.,OCHIN, Inc., Portland, OR, USA
| |
Collapse
|
12
|
Galea S, Vaughan R. A Public Health of Consequence: Review of the April 2016 Issue of AJPH. Am J Public Health 2016; 106:592-3. [PMID: 26959255 DOI: 10.2105/ajph.2016.303109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sandro Galea
- Sandro Galea is Dean and Professor, School of Public Health, Boston University, Boston, MA. Roger Vaughan is an AJPH editor, and is also the Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Roger Vaughan
- Sandro Galea is Dean and Professor, School of Public Health, Boston University, Boston, MA. Roger Vaughan is an AJPH editor, and is also the Vice Dean and Professor of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| |
Collapse
|