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Research ArticleOriginal Research

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

Nathalie Huguet, Rachel Springer, Miguel Marino, Heather Angier, Megan Hoopes, Heather Holderness and Jennifer E. DeVoe
The Journal of the American Board of Family Medicine November 2018, 31 (6) 905-916; DOI: https://doi.org/10.3122/jabfm.2018.06.180075
Nathalie Huguet
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Rachel Springer
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Miguel Marino
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Heather Angier
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Megan Hoopes
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Heather Holderness
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Jennifer E. DeVoe
Department of Family Medicine, Oregon Health & Science University, Portland OR (NH, RS, MM, HA, HH, JEDV); Biostatistics Group, Oregon Health & Science University – Portland State University School of Public Health, Portland (MM); Research Department, OCHIN, Inc., Portland (MH).
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Article Figures & Data

Tables

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    Table 1.

    Characteristics of Community Health Centers and Patients in the Accelerating Data Value Across a National Community Health Center Network Clinical Data Research Network from 2012 to 2015

    Nonexpansion StatesExpansion States
    Community health center/state-level covariates
    StatesFL, KS, MO, NCCA, HI, MD, NM, OH, OR, RI, WA, WI
    No. eligible CHCs67131
    No. rural CHCs (%)3 (4.5)23 (17.6)
    No. urban CHCs (%)64 (95.5)108 (82.4)
    Marketplace type, n (%)
        Federally supported, state-based075 (57.3)
        Federal67 (100)13 (9.9)
        State043 (32.8)
    Minimum wage, 2013, mean $/h$7.73$8.26
    Unemployment rate, 2013, mean %7.26%7.91%
    Adult uninsured rate, 2013, mean %25.07%17.62%
    Patient-level covariates
    CountDiabetesPrediabetesNo DiabetesDiabetesPrediabetesNo Diabetes
    Total no. patients48,38269,476270,60858,20587,020338,687
    Established patient visit count pre-ACA, n217,063238,129476,218379,394414,318806,398
    Established patient visit count post-ACA, n168,026198,079310,978332,773384,859583,975
    New patient visit count pre-ACA, n8,9289,38911,57829,89511,99813,134
    New patient visit count post-ACA, n58,02873,017167,133298,17876,325105,671
    Female, n (%)27,485 (56.8)42,546 (61.2)173,390 (64.1)31,250 (53.7)46,312 (53.2)191,485 (56.5)
    Age group, n (%)
        19 to 25 y1,375 (2.8)3,745 (5.4)59,453 (22.0)1,923 (3.3)5,867 (6.7)81,296 (24.0)
        26 to 39 y7,834 (16.2)16,511 (23.8)101,157 (37.4)11,043 (19.0)24,507 (28.2)132,408 (39.1)
        40 to 64 y39,173 (81.0)49,220 (70.8)109,998 (40.6)45,239 (77.7)56,646 (65.1)124,983 (36.9)
    Household income, n (%)
        ⩽100% FPL33,779 (69.8)46,543 (67.0)181,044 (66.9)33,721 (57.9)50,324 (57.8)182,657 (53.9)
        100% to 138% FPL4,912 (10.2)6,856 ( 9.9)27,891 (10.3)7,199 (12.4)11,004 (12.6)37,128 (11.0)
        ⩽138% FPL5,834 (12.1)9,329 (13.4)32,457 (12.0)8,099 (13.9)13,304 (15.3)52,517 (15.5)
        Unknown3,857 (8.0)6,748 (9.7)29,216 (10.8)9,186 (15.8)12,388 (14.2)66,385 (19.6)
    Race/ethnicity, n (%)
        Hispanic16,935 (35.0)27,100 (39.0)101,690 (37.6)22,230 (38.2)28,572 (32.8)98,218 (29.0)
        NH non-white17,165 (35.5)21,070 (30.3)71,111 (26.3)9,431 (16.2)12,800 (14.7)48,178 (14.2)
        NH white12,461 (25.8)18,481 (26.6)85,897 (31.7)24,294 (41.7)42,040 (48.3)173,868 (51.3)
        Unknown1,821 (3.8)2,825 (4.1)11,910 (4.4)2,250 (3.9)3,608 (4.1)18,423 (5.4)
    • ACA, Affordable Care Act; CHC, community health center; FPL, federal poverty level; NH, non-Hispanic.

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    Table 2.

    Visit Rates Before and After Affordable Care Act, Accelerating Data Value Across a National Community Health Center Network Clinical Data Research Network from 2012 to 2015*

    Patient InformationUnadjusted Visit RateCovariate Adjusted Visit Rate
    Nonexpansion StateExpansion StateNonexpansion StateAbsolute Rate DifferenceExpansion StateAbsolute Rate Difference
    Pre-ACAPost-ACAPre-ACAPost-ACAPre-ACAPost-ACAPrePost
    Uninsured
        Diabetes61.252.075.333.243.236.7−6.563.127.8−35.3
        Prediabetes52.645.152.425.239.834.1−5.750.124.1−26.0
        No diabetes30.224.631.414.727.622.5−5.137.217.4−19.8
    Medicaid
        Diabetes37.437.180.0125.635.835.5−0.362.798.435.7
        Prediabetes29.431.470.4120.027.929.92.048.983.534.6
        No diabetes15.015.031.750.620.620.5−0.136.558.321.8
    Privately insured
        Diabetes9.726.934.037.516.044.228.219.221.22.0
        Prediabetes9.931.531.334.518.057.039.020.222.32.1
        No diabetes4.712.618.419.512.032.320.314.515.40.9
    Other public
        Diabetes36.428.839.943.247.737.7−10.021.623.41.8
        Prediabetes28.724.126.928.048.340.5−7.815.816.40.6
        No diabetes13.29.77.87.029.621.7−7.96.15.5−0.6
    Total Visits
        Diabetes144.8144.8229.2239.5169.9169.90.0177.8185.88.0
        Prediabetes120.6132.1181.0207.7148.8163.014.2140.2160.920.7
        No diabetes63.161.989.391.999.197.2−1.990.993.62.7
    Primary care visits
        Diabetes122.6120.6190.1195.8132.9130.7−2.2140.7144.94.2
        Prediabetes103.6111.6152.8173.6120.9130.29.3118.0134.116.1
        No diabetes54.852.775.476.690.887.4−3.486.287.71.5
    Preventive care visits
        Diabetes4.75.94.14.66.68.31.72.93.20.3
        Prediabetes7.09.45.26.810.213.83.64.55.91.4
        No diabetes5.87.04.65.19.911.92.04.34.70.4
    Glucose testing
        Diabetes67.481.976.687.665.479.514.178.289.511.3
        Prediabetes36.345.035.844.233.942.08.135.343.68.3
        No diabetes12.214.711.114.318.522.33.819.324.85.5
    HbA1c screening
        Diabetes52.376.365.582.753.878.424.670.989.518.6
        Prediabetes16.028.010.220.314.425.310.910.420.710.3
        No diabetes2.64.31.33.03.25.52.32.35.22.9
    • ACA, Affordable Care Act.

    • ↵* Nonexpansion states: FL, KS, MO, and NC; expansion states: CA, HI, MD, NM, OH, OR, RI, WA, and WI. Visit rates were by dividing the number of visits in a given interval (ie, pre-ACA or post-ACA period) by the total number of adult patients seen in a clinic over the study period, scaled to 1000 patients per month. Total visits: Current Procedural Terminology (CPT) 99201 to 99205, 99212 to 99215, 99241 to 99245, 99381 to 99384, 99385 to 99387, or 99391 to 99397 with MD, DO, NP, PA, midwife, or resident with no specialty listed. Generalized estimating equation Poisson models adjusted for clinic-level demographic distributions (sex, age, federal poverty level, primary language, race, and ethnicity), state-level factors (marketplace type, 2013 minimum wage and unemployment rates, and 2013 uninsured rate), and 2013 state-level CHCs diabetes prevalence (https://bphc.hrsa.gov/datareporting/index.html) clustered by facility to account for within-facility correlation.

    • View popup
    Table 3.

    Adjusted Rate Ratios and Difference-in-Difference in Visit Rates by Diabetes Status and Medicaid Expansion Status, Accelerating Data Value Across a National Community Health Center Network Clinical Data Research Network from 2012 to 2015*

    Patient InformationNonexpansionExpansionExpansion vs Nonexpansion
    Post-ACA vs Pre-ACAPost-ACA vs Pre-ACA
    RR (95% CI)RR (95% CI)DD Ratio (95% CI)
    Uninsured
        Diabetes0.85 (0.76–0.94)0.44 (0.39–0.49)0.52 (0.44–0.60)
        Prediabetes0.86 (0.76–0.95)0.48 (0.42–0.54)0.56 (0.47–0.65)
        No diabetes0.82 (0.74–0.89)0.47 (0.42–0.52)0.57 (0.50–0.65)
    Medicaid
        Diabetes0.99 (0.92–1.07)1.57 (1.43–1.71)1.58 (1.40–1.77)
        Prediabetes1.07 (0.98–1.16)1.71 (1.53–1.88)1.59 (1.38–1.80)
        No diabetes1.00 (0.91–1.09)1.60 (1.46–1.73)1.60 (1.40–1.80)
    Privately insured
        Diabetes2.77 (1.79–3.75)1.10 (0.96–1.25)0.40 (0.25–0.55)
        Prediabetes3.17 (2.03–4.31)1.10 (0.90–1.31)0.35 (0.21–0.49)
        No diabetes2.70 (2.02–3.38)1.06 (0.94–1.18)0.39 (0.28–0.50)
    Other public
        Diabetes0.79 (0.66–0.92)1.08 (0.97–1.20)1.37 (1.10–1.64)
        Prediabetes0.84 (0.65–1.03)1.04 (0.86–1.22)1.24 (0.89–1.59)
        No diabetes0.73 (0.59–0.87)0.90 (0.77–1.04)1.24 (0.94–1.53)
    Total visit
        Diabetes1.00 (0.93–1.07)1.05 (0.99–1.09)1.04 (0.95–1.14)
        Prediabetes1.10 (1.00–1.19)1.15 (1.09–1.20)1.05 (0.94–1.16)
        No diabetes0.98 (0.91–1.06)1.03 (0.98–1.08)1.05 (0.95–1.15)
    Primary care
        Diabetes0.98 (0.91–1.06)1.03 (0.98–1.07)1.05 (0.96–1.14)
        Prediabetes1.08 (0.98–1.17)1.14 (1.08–1.19)1.05 (0.95–1.16)
        No diabetes0.96 (0.88–1.04)1.02 (0.96–1.07)1.06 (0.95–1.16)
    Preventive Care
        Diabetes1.26 (1.03–1.50)1.12 (1.02–1.23)0.89 (0.71–1.08)
        Prediabetes1.35 (1.13–1.58)1.31 (1.19–1.42)0.96 (0.79–1.14)
        No diabetes1.20 (1.04–1.37)1.11 (1.01–1.20)0.92 (0.77–1.07)
    Glucose testing
        Diabetes1.22 (1.11–1.32)1.14 (1.09–1.20)0.94 (0.84–1.04)
        Prediabetes1.24 (1.13–1.35)1.23 (1.17–1.30)0.99 (0.89–1.09)
        No diabetes1.20 (1.09–1.31)1.29 (1.21–1.37)1.07 (0.95–1.19)
    HbA1c screening
        Diabetes1.46 (1.35–1.56)1.26 (1.21–1.31)0.87 (0.80–0.94)
        Prediabetes1.76 (1.56–1.95)2.00 (1.80–2.19)1.14 (0.87–1.40)
        No diabetes1.70 (1.45–1.96)2.26 (1.97–2.56)1.33 (1.09–1.57)
    • ACA, Affordable Care Act; RR, rate ratio; CI, confidential interval; DD, difference-in-difference testing post-period versus pre-period in expansion versus non-expansion states.

    • ↵* Nonexpansion states: FL, KS, MO, and NC; expansion states: CA, HI, MD, NM, OH, OR, RI, WA, and WI. Visit rates were by dividing the number of visits in a given interval (ie, pre-ACA or post-ACA period) by the total number of adult patients seen in a clinic over the study period, scaled to 1000 patients per month. Boldfaced values indicate statistically significant difference, P < .05. Total visits: CPT 99201 to 99205, 99212 to 99215, 99241 to 99245, 99381 to 99384, 99385 to 99387, or 99391 to 99397 with MD, DO, NP, PA, midwife, or resident with no specialty listed. Generalized estimating equation Poisson models adjusted for clinic-level demographic distributions (sex, age, federal poverty level, primary language, race, and ethnicity), state-level factors (marketplace type, 2013 minimum wage and unemployment rates, 2013 uninsured rate), and 2013 state-level CHCs diabetes prevalence (https://bphc.hrsa.gov/datareporting/index.html) clustered by facility to account for within-facility correlation. DD estimates obtained from linear combinations of time × expansion status interaction.

    • View popup
    Appendix:

    Community Health Center Visit Rates Before and After Affordable Care Act in Expansion and Nonexpansion States, Accelerating Data Value Across a National Community Health Center Network Clinical Data Research Network from 2012 to 2015

    Patient InformationModel Excluding State-Level Factors*Model Adjusting for State-Level Factors Excluding DM Prevalence†Model Adjusting for State-Level Factors and State DM Prevalence‡
    Nonexpansion Visit RateExpansion Visit RateNonexpansion Visit RateExpansion Visit RateNonexpansion Visit RateExpansion Visit Rate
    PrePostPrePostPrePostPrePostPrePostPrePost
    Uninsured
        DM50.142.662.927.843.236.763.127.846.639.661.927.3
        Pre-DM44.838.445.421.839.834.150.124.142.836.748.623.3
        No DM36.529.840.118.827.622.537.217.429.423.935.716.7
    Medicaid
        DM32.932.767.8106.335.835.562.798.437.036.762.898.5
        Pre-DM25.227.053.691.427.929.948.983.528.630.748.582.7
        No DM19.119.140.063.920.620.536.558.320.820.735.957.3
    Privately insured
        DM9.426.027.830.716.044.219.221.216.646.019.221.2
        Pre-DM10.433.130.834.018.057.020.222.318.658.919.922.0
        No DM6.016.119.520.612.032.314.515.412.132.814.115.0
    Other public
        DM27.521.732.134.847.737.721.623.449.238.821.423.2
        Pre-DM26.322.123.524.448.340.515.816.449.741.615.616.2
        No DM15.011.08.07.229.621.76.15.530.422.26.05.4
    Total visit
        DM139.1139.1210.0219.5169.9169.9177.8185.8180.6180.7176.7184.7
        Pre-DM116.8128.0160.5184.1148.8163.0140.2160.9157.0171.9137.3157.6
        No DM74.973.499.4102.399.197.290.993.6102.6100.687.790.3
    Primary care
        DM109.1107.3162.9167.7132.9130.7140.7144.9140.3138.0140.3144.5
        Pre-DM96.4103.8134.5152.7120.9130.2118.0134.1126.6136.4116.0131.7
        No DM70.467.894.896.390.887.486.287.793.590.083.584.9
    Preventive care
        DM4.75.94.14.76.68.32.93.27.18.92.93.2
        Pre-DM6.68.96.07.810.213.84.55.910.814.74.45.7
        No DM5.66.74.85.39.911.94.34.710.412.54.14.5
    Glucose testing
        DM71.687.071.581.865.479.578.289.564.077.878.689.8
        Pre-DM38.347.533.240.933.942.035.343.633.241.235.643.9
        No DM20.925.218.223.518.522.319.324.818.221.919.525.1
    HbA1c screening
        DM58.885.768.586.453.878.470.989.557.383.570.388.7
        Pre-DM15.727.69.919.814.425.310.420.715.226.710.120.2
        No DM3.45.92.25.03.25.52.35.23.35.72.25.1
    • ACA, Affordable Care Act; DM, diabetes mellitus; pre, pre-ACA; post, post-ACA.

    • ↵* Adjusted for clinic-level distributions of sex, age, race/ethnicity, and federal poverty level, urban vs. rural clinic location.

    • ↵† Adjusted for clinic-level distributions of sex, age, race/ethnicity, and federal poverty level, urban vs. rural clinic location, and state-level factors (type of health insurance marketplace [state-run or federally facilitated], 2013 minimum wage, 2013 uninsured rate, and 2013 unemployment rate).

    • ↵‡ Adjusted for clinic-level distributions of sex, age, race/ethnicity, and federal poverty level, urban vs. rural clinic location, and state-level factors (type of health insurance marketplace [state-run or federally facilitated], 2013 minimum wage, 2013 uninsured rate, and 2013 unemployment rate), state-level 2013 CHCs DM prevalence (source, HRSA, Health Center Data & Reporting, https://bphc.hrsa.gov/datareporting/index.html).

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November-December 2018
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The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers
Nathalie Huguet, Rachel Springer, Miguel Marino, Heather Angier, Megan Hoopes, Heather Holderness, Jennifer E. DeVoe
The Journal of the American Board of Family Medicine Nov 2018, 31 (6) 905-916; DOI: 10.3122/jabfm.2018.06.180075

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The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers
Nathalie Huguet, Rachel Springer, Miguel Marino, Heather Angier, Megan Hoopes, Heather Holderness, Jennifer E. DeVoe
The Journal of the American Board of Family Medicine Nov 2018, 31 (6) 905-916; DOI: 10.3122/jabfm.2018.06.180075
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