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Research ArticleOriginal Research

Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act

Nathalie Huguet, Heather Angier, Megan J. Hoopes, Miguel Marino, John Heintzman, Teresa Schmidt and Jennifer E. DeVoe
The Journal of the American Board of Family Medicine November 2019, 32 (6) 883-889; DOI: https://doi.org/10.3122/jabfm.2019.06.190087
Nathalie Huguet
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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Heather Angier
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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Megan J. Hoopes
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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Miguel Marino
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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John Heintzman
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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Teresa Schmidt
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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Jennifer E. DeVoe
the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University–Portland State University School of Public Health, Portland, OR (MM).
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    Table 1.

    Prevalence of Pre-existing Conditions and Adjusted Comparisons, Among a Cohort of Established CHC Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Insurance Type and Race/Ethnicity

    NPre-ACA, n (%)Post-ACA, n (%)Adjusted Absolute Prevalence Difference, Post vs Pre-ACA (95% CI)
    Insurance type
        Gained Medicaid50,83931,454 (61.9)40,008 (78.7)+16.8 (16.5, 17.2)
        Gained Private27,22014,080 (51.7)18,987 (69.8)+18.0 (17.6, 18.5)
    Race/ethnicity
        Non-Hispanic White29,76420,491 (68.8)25,179 (84.6)+15.8 (15.4, 16.2)
        Hispanic30,29615,108 (49.9)20,626 (68.1)+18.3 (17.8, 18.7)
        Non-Hispanic Black13,0907413 (56.6)9827 (75.1)+18.9 (18.2, 19.6)
    • CHC, community health center; CI, confidence interval.

    • Data from 386 community health centers in 19 states (AK, CA, FL, HI, KS, MD, MN, MO, MT, NC, NM, NV, OH, OR, RI, TX, WA, WI). The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015). Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions. We computed within-race/ethnicity and insurance type-group prevalence differences of having at least one pre-existing condition post- vs pre-ACA. Adjusted estimates obtained from generalized estimating equation models specifying a Gaussian distribution, identity link function, an independent working correlation matrix with robust standard errors and adjusted for sex, age, federal poverty level, number of visits, race-ethnicity (insurance type models), post-ACA insurance type (racial/ethnic models), state Medicaid expansion status, and health system. Standard errors were clustered by patient nested within their primary clinic to account for temporal correlation of observations within patients over the ACA periods and intracluster correlation of patients within clinics. Pre-post prevalence differences were significant (P < .001) for all comparisons.

    • View popup
    Table 2.

    Prevalence of Top 5 Conditions Pre- and Post-ACA, Among a Cohort of Established Community Health Center Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Insurance Type

    Gained Medicaid (N = 50,839)Gained Private (N = 27,220)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
    Alcohol and drug abuse6,005 (11.8)10,067 (19.8)1,087 (4.0)2,084 (7.7)
    Asthma and COPD7,452 (14.7)10,679 (21.0)2,865 (10.5)4,141 (15.2)
    Diabetes7,163 (14.1)8,826 (17.4)3,982 (14.6)4,834 (17.8)
    Mental health disorders17,077 (33.6)23,199 (45.6)5,899 (21.7)8,292 (30.5)
    Obesity8,523 (16.8)12,972 (25.5)4,050 (14.9)6,240 (22.9)
    • COPD, chronic obstructive pulmonary disease, and emphysema.

    • Data from 386 community health centers in 19 states (AK, CA, FL, HI, KS, MD, MN, MO, MT, NC, NM, NV, OH, OR, RI, TX, WA, WI). The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015). Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions.

    • View popup
    Table 3.

    Prevalence of Top 5 Conditions Pre- and Post-ACA, Among a Cohort of Established Community Health Center Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Race/Ethnicity

    Non-Hispanic White (N = 29,764)Hispanic (N = 30,296)Non-Hispanic Black (N = 13,090)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
    Alcohol and drug abuse4,576 (15.4)7,645 (25.7)1,025 (3.4)1,881 (6.2)1,111 (8.5)1,973 (15.1)
    Asthma, COPD5,561 (18.7)7,960 (26.7)2,518 (8.3)3,697 (12.2)1,653 (12.6)2,314 (17.7)
    Diabetes3,433 (11.5)4,212 (14.2)4,661 (15.4)5,680 (18.7)2,388 (18.2)2,933 (22.4)
    Mental health disorders12,807 (43.0)16,666 (56.0)6,657 (22.0)9,612 (31.7)2,380 (18.2)3,619 (27.6)
    Obesity4,743 (15.9)7,186 (24.1)4,850 (16.0)7,391 (24.4)2,480 (18.9)3,820 (29.2)
    • COPD, chronic obstructive pulmonary disease, & emphysema.

    • Data from 386 community health centers in 19 states (AK, CA, FL, HI, KS, MD, MN, MO, MT, NC, NM, NV, OH, OR, RI, TX, WA, WI). The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015). Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions.

    • View popup
    Appendix Table 1.

    Prevalence of Pre-existing Conditions and Adjusted Comparisons, Among a Cohort of Established Community Health Center Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Insurance Type, Race/Ethnicity, and Medicaid Expansion State Status

    Medicaid Expansion State ≤1 ConditionNon-Expansion State ≥1 Condition
    NPre-ACA, n (%)Post-ACA, n (%)Adjusted Absolute Prevalence Difference, Post vs Pre-ACA (95% CI)NPre-ACA, n (%)Post-ACA, n (%)Adjusted Absolute Prevalence Difference, Post vs Pre-ACA (95% CI)
    Insurance type
        Gained Medicaid39,52025,513 (64.6)32,034 (81.1)+16.5 (16.2, 16.9)11,3195,941 (52.5)7,974 (70.4)+17.9 (17.3, 18.7)
        Gained Private11,1875,841 (52.2)7,717 (69.0)+16.8 (16.1, 17.5)16,0338,239 (51.4)11,270 (70.3)+18.9 (18.3, 19.5)
    Race/Ethnicity
        Non-Hispanic White22,83516,135 (70.7)19,615 (85.9)+15.3 (14.8, 15.7)6,9294,356 (62.9)5,564 (80.3)+17.4 (16.5, 18.3)
        Hispanic19,51210,479 (53.7)13,967 (71.6)+17.9 (17.4, 18.4)10,7844,629 (42.9)6,659 (61.7)+18.8 (18.1, 19.6)
        Non-Hispanic Black4,7872,789 (58.3)3,614 (75.5)+17.2 (16.2, 18.3)8,3034,624 (55.7)6,213 (74.8)+19.1 (18.3, 20.0)
    • CI, confidence interval.

    • Data from 386 community health centers in 19 states (11 expansion, 8 non-expansion). Expansion states include: CA, HI, MD, MN, NM, NV, OH, OR, RI, WI, WA; Non-Expansion states include: AK, FL, IN, KS, MO, MT, NC, TX. The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015).

    • Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions. We computed within-race/ethnicity and insurance type–group prevalence differences of having at least one pre-existing condition post- vs pre-ACA. Adjusted estimates obtained from generalized estimating equation models specifying a Gaussian distribution, identity link function, an independent working correlation matrix with robust standard errors and adjusted for sex, age, federal poverty level, number of visits, race-ethnicity (insurance type models), post-ACA insurance type (racial/ethnic models), state Medicaid expansion status, and health system. Standard errors were clustered by patient nested within their primary clinic to account for temporal correlation of observations within patients over the ACA periods and intracluster correlation of patients within clinics. Pre-post prevalence differences were significant (P < .001) for all comparisons. Sensitivity analysis excluding WI did not result in any substantial differences in point estimates or statistical significance.

    • View popup
    Appendix Table 2.

    Prevalence of Top 5 Conditions Pre- and Post-ACA, Among a Cohort of Established CHC Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Insurance Type and Medicaid Expansion State Status

    Expansion States
    Gained Medicaid (N = 39,520)Gained Private (N = 11,187)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
        Alcohol and drug abuse5,193 (13.1)8,515 (21.5)490 (4.4)876 (7.8)
        Asthma, COPD6,131 (15.5)8,727 (22.1)1,368 (12.2)1,909 (17.1)
        Diabetes5,669 (14.3)6,962 (17.6)1,350 (12.1)1,617 (14.5)
        Mental health disorders14,537 (36.8)19,293 (48.8)2,854 (25.5)3,827 (34.2)
        Obesity6,852 (17.3)10,260 (26.0)1,594 (14.2)2,363 (21.1)
    Non-expansion States
    Gained Medicaid (N = 11,319)Gained Private (N = 16,033)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
        Alcohol and drug abuse812 (7.2)1,552 (13.7)597 (3.7)1,208 (7.5)
        Asthma, COPD1,321 (11.7)1,952 (17.2)1,497 (9.3)2,232 (13.9)
        Diabetes1,494 (13.2)1,864 (16.5)2,632 (16.4)3,217 (20.1)
        Mental health disorders2,540 (22.4)3,906 (34.5)3,045 (19.0)4,465 (27.8)
        Obesity1,671 (14.8)2,712 (24.0)2,456 (15.3)3,877 (24.2)
    • COPD, chronic obstructive pulmonary disease, & emphysema; CHC, community health center.

    • Data from 386 community health centers in 19 states (11 expansion, 8 non-expansion). Expansion states include: CA, HI, MD, MN, NM, NV, OH, OR, RI, WI, WA; Non-Expansion states include: AK, FL, IN, KS, MO, MT, NC, TX. The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015). Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions.

    • View popup
    Appendix Table 3.

    Prevalence of Top 5 Conditions Pre- and Post-ACA, Among a Cohort of Established CHC Patients Pre- and Post-Implementation of the Affordable Care Act (ACA) Insurance Expansions in 2014, by Race/Ethnicity and Medicaid Expansion State Status

    Expansion States
    Non-Hispanic White (N = 22,835)Hispanic (N = 19,512)Non-Hispanic Black (N = 4,787)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
        Alcohol and drug abuse3,927 (17.2)6,449 (28.2)765 (3.9)1,336 (6.8)672 (14.0)1,060 (22.1)
        Asthma, COPD4,489 (19.7)6,395 (28.0)1,797 (9.2)2,558 (13.1)752 (15.7)1,018 (21.3)
        Diabetes2,515 (11.0)3,112 (13.6)3,238 (16.6)3,929 (20.1)782 (16.3)941 (19.7)
        Mental health disorders10,372 (45.4)13,336 (58.4)4,918 (25.2)6,897 (35.3)1,145 (23.9)1,586 (33.1)
        Obesity3,787 (16.6)5,632 (24.7)3,482 (17.8)5,189 (26.6)785 (16.4)1,185 (24.8)
    Non-expansion States
    Non-Hispanic White (N = 6,929)Hispanic (N = 10,784)Non-Hispanic Black (N = 8,303)
    Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)Pre, n (%)Post, n (%)
        Alcohol & drug abuse649 (9.4)1,196 (17.3)260 (2.4)545 (5.1)439 (5.3)913 (11.0)
        Asthma, COPD1,072 (15.5)1,565 (22.6)721 (6.7)1,139 (10.6)901 (10.9)1,296 (15.6)
        Diabetes918 (13.2)1,100 (15.9)1,423 (13.2)1,751 (16.2)1,606 (19.3)1,992 (24.0)
        Mental health disorders2,435 (35.1)3,330 (48.1)1,739 (16.1)2,715 (25.2)1,235 (14.9)2,033 (24.5)
        Obesity956 (13.8)1,554 (22.4)1,368 (12.7)2,202 (20.4)1,695 (20.4)2,635 (31.7)
    • COPD, chronic obstructive pulmonary disease, & emphysema, CHC, community health center.

    • Data from 386 community health centers in 19 states (11 expansion, 8 non-expansion). Expansion states include CA, HI, MD, MN, NM, NV, OH, OR, RI, WI, WA; Non-expansion states include AK, FL, IN, KS, MO, MT, NC, TX. The retrospective cohort of established patients included those who were uninsured at their last visit pre-ACA (2012 to 2013) and gained insurance coverage post-ACA (2014 to 2015). Conditions identified by ICD 9/10 codes in patients' problem lists or encounter diagnoses based on the Henry J Kaiser Family Foundation list of declinable conditions.

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The Journal of the American Board of Family     Medicine: 32 (6)
The Journal of the American Board of Family Medicine
Vol. 32, Issue 6
November-December 2019
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Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act
Nathalie Huguet, Heather Angier, Megan J. Hoopes, Miguel Marino, John Heintzman, Teresa Schmidt, Jennifer E. DeVoe
The Journal of the American Board of Family Medicine Nov 2019, 32 (6) 883-889; DOI: 10.3122/jabfm.2019.06.190087

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Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act
Nathalie Huguet, Heather Angier, Megan J. Hoopes, Miguel Marino, John Heintzman, Teresa Schmidt, Jennifer E. DeVoe
The Journal of the American Board of Family Medicine Nov 2019, 32 (6) 883-889; DOI: 10.3122/jabfm.2019.06.190087
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