The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers

• Published in: Journal of the American Board of Family Medicine Vol. 31; no. 6; pp. 905 - 916
• Main Authors: Huguet, Nathalie, Springer, Rachel, Marino, Miguel, Angier, Heather, Hoopes, Megan, Holderness, Heather, DeVoe, Jennifer E
• Format: Journal Article
• Language: English
• Published: United States 01.11.2018
• Subjects: Adult; Community Health Centers - economics; Community Health Centers - statistics & numerical data; Diabetes Mellitus - diagnosis; Diabetes Mellitus - economics; Diabetes Mellitus - therapy; Electronic Health Records - statistics & numerical data; Female; Health Services Accessibility - economics; Health Services Accessibility - statistics & numerical data; Humans; Insurance, Physician Services - statistics & numerical data; Longitudinal Studies; Male; Medicaid - economics; Medicaid - statistics & numerical data; Medically Uninsured - statistics & numerical data; Middle Aged; Patient Protection and Affordable Care Act; Primary Health Care - economics; Primary Health Care - statistics & numerical data; Safety-net Providers - economics; Safety-net Providers - statistics & numerical data; United States; Young Adult; United States; Medically Uninsured; Prediabetic State; Community Health Centers; Primary Health Care; Diabetes Mellitus; Medicaid; Hemoglobins; Cohort Studies
• ISSN: 1557-2625; 1558-7118
• DOI: 10.3122/jabfm.2018.06.180075

To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion. Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes. Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states. The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.