Insurance Instability Among Community-Based Health Center Patients with Diabetes Post-Affordable Care Act Medicaid Expansion

Leo Lester; Dang Dinh; Annie E. Larson; Andrew Suchocki; Miguel Marino; Jennifer DeVoe; Nathalie Huguet

doi:10.3122/jabfm.2024.240186R1

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Table 1.

Percent and Adjusted Odds of Insurance Churning Among Patients Seen in Community-Based Health Centers from 2014 to 2019*

	Total N = 300,158		Churned out of Insurance N = 39,542		Did Not Churn out of Insurance N = 260,616		aOR of Churning (95% CI)
	N	Col %	N	Row %	N	Row %	aOR of Churning (95% CI)
Diabetes diagnosis
Yes	44,864	14.9	7,954	17.7	36,910	82.3	1.25 (1.18, 1.33)
No	255,294	85.1	31,588	12.4	223,706	87.6	Reference
Sex
Female	184,675	61.5	26,990	14.6	157,685	85.4	Reference
Male	115,483	38.5	12,552	10.9	102,931	89.1	0.76 (0.71, 0.82)
Age at baseline visit
19 to 44	166,869	55.6	21,819	13.1	145,050	86.9	Reference
45 to 64	133,289	44.4	17,723	13.3	115,566	86.7	0.86 (0.81, 0.90)
Race/Ethnicity
Non-Hispanic White	129,756	43.2	11,940	9.2	117,816	90.8	Reference
Hispanic	94,817	31.6	16,986	17.9	77,831	82.1	1.87 (1.58, 2.22)
Non-Hispanic Black	46,497	15.5	7,742	16.7	38,755	83.3	1.73 (1.50, 1.99)
Non-Hispanic Other	13,880	4.6	1,183	8.5	12,697	91.5	0.85 (0.75, 0.98)
Missing	15,208	5.1	1,691	11.1	13,517	88.9	1.24 (1.09, 1.41)
Federal poverty level
≤138%	211,177	70.4	30,672	14.5	180,505	85.5	1.31 (1.17, 1.47)
>138%	54,467	18.1	6,662	12.2	47,805	87.8	Reference
Missing	34,514	11.5	2,208	6.4	32,306	93.6	0.59 (0.46, 0.76)
Patients’ residence
Rural	81,695	27.2	8,548	10.5	73,147	89.5	Reference
Urban	218,463	72.8	30,994	14.2	187,469	85.8	1.16 (0.93, 1.46)
Baseline payor type
Medicaid	194,208	64.7	22,863	11.8	171,345	88.2	Reference
Private insurance	105,950	35.3	16,679	15.7	89,271	84.3	1.68 (1.47, 1.92)
Comorbidities excluding diabetes
Mental health disorder only	37,487	12.5	4,582	12.2	32,905	87.8	1.06 (0.99, 1.14)
Physical comorbidity only	76,575	25.5	12,009	15.7	64,566	84.3	1.16 (1.10, 1.24)
Mental health and physical comorbidity	44,404	14.8	5,741	12.9	38,663	87.1	1.00 (0.91, 1.09)
None	141,692	47.2	17,210	12.1	124,482	87.9	Reference
Mean ambulatory visits, N (SD)	12.6	11.4	15.4	13.7	12.2	11.0	1.02 (1.01, 1.03)

Abbreviations: aOR, Adjusted odds ratio; CI, Confidence interval; SD, Standard deviation.
*Sample included non-pregnant patients aged 19-64 without Medicare coverage who had a baseline insured visit between 2014 and 2017, with ≥3 ambulatory visits occurring within the subsequent 3-year period, and at least 12 months separating the first and last of these visits between 2014 and 2019. Those who churned were defined as having ≥2 consecutive uninsured visits. Those who did not churn included those who had every visit insured or those who had one single uninsured. χ² tests for categorical variables and t test for continuous variables were used to test for differences between churning groups, except for age groups, all were significant at P < .001.
Bolded estimates are significant at P < .05.

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Table 2.

Percent and Adjusted Odds of Insurance Churning Among Patients with Diabetes Seen in Community-Based Health Centers from 2014 to 2019*

	Churned out of Insurance (n = 7954)		Did Not Churn out of Insurance (n = 36,910)		aOR of Churning (95% CI)
	N	Row %	N	Row %	aOR of Churning (95% CI)
Sex
Female	4,970	19.7	20,235	80.3	Reference
Male	2,984	15.2	16,675	84.8	0.78 (0.72, 0.84)
Age
19 to 44	2,421	18.3	10,832	81.7	Reference
45 to 64	5,533	17.5	26,078	82.5	0.87 (0.81, 0.93)
Race/Ethnicity
Non-Hispanic White	1,694	12.1	12,296	87.9	Reference
Hispanic	3,897	22.1	13,725	77.9	1.81 (1.50, 2.19)
Non-Hispanic Black	1,803	19.8	7,305	80.2	1.58 (1.35, 1.85)
Non-Hispanic Other	266	12.4	1,872	87.6	0.96 (0.81, 1.14)
Missing	294	14.7	1,712	85.3	1.21 (1.04, 1.42)
Federal poverty level
≤138%	6,354	18.7	27,595	81.3	1.33 (1.15, 1.54)
>138%	1,276	16.9	6,283	83.1	Reference
Missing	324	9.7	3,032	90.3	0.68 (0.45, 1.03)
Patients’ residence
Rural	1,566	15.6	8,496	84.4	Reference
Urban	6,388	18.4	28,414	81.6	1.12 (0.87, 1.44)
Baseline payor type
Medicaid	4,464	15.0	25,306	85.0	Reference
Private insurance	3,490	23.1	11,604	76.9	1.94 (1.68, 2.25)
Comorbidities excluding diabetes
Mental health disorder only	310	16.1	1,616	83.9	0.99 (0.83, 1.18)
Physical comorbidity only	4,423	19.1	18,708	80.9	1.08 (0.99, 1.17)
Mental health and physical comorbidity	1,864	15.7	10,002	84.3	0.93 (0.84, 1.04)
None	1,357	17.1	6,584	82.9	Reference
Mean ambulatory visits, N (SD)	19.5	15.7	16.9	12.8	1.01 (1.00, 1.01)
HbA1c control
≤9	5,343	16.4	2,7182	83.6	Reference
>9	2,465	21.9	8,782	78.1	1.33 (1.24, 1.43)
Missing	146	13.4	946	86.6	1.10 (0.87, 1.39)
Diabetes medication regimen complexity
No medication	946	12.7	6,498	87.3	Reference
Lower complexity	4,874	18.0	22,155	82.0	1.35 (1.24, 1.47)
High complexity	2,134	20.5	8,257	79.5	1.33 (1.19, 1.49)
Ever with insulin
Yes	3,496	19.6	14,360	80.4	1.06 (0.98, 1.13)
No	4,458	16.5	22,550	83.5	Reference
Acute complications during study period
0	6,614	17.2	31,764	82.8	Reference
1	807	21.6	2,922	78.4	1.20 (1.08, 1.33)
≥ 2	533	19.3	2,224	80.7	1.00 (0.87, 1.15)

Abbreviations: aOR, Adjusted odds ratio, CI, Confidence interval.
*Sample included non-pregnant patients aged 19-64 without Medicare coverage who had a baseline insured visit between 2014 and 2017, with ≥3 ambulatory visits occurring within the subsequent 3-year period, and at least 12 months separating the first and last of these visits between 2014 and 2019. Those who churned were defined as having ≥2 consecutive uninsured visits. Those who did not churn included those who had every visit insured or those who had one single uninsured. χ² tests for categorical variables and t test for continuous variables were used to test for differences between churning groups, except for age groups, all were significant at P <.001. Bolded estimates are significant at P < .05.

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Appendix Table 1.

Number and Percent of Insurance Churning Among Patients with Diabetes Seen in Community-Based Health Centers by State from 2014 to 2019*

State	Patients with Diabetes N	Patients with Diabetes who Churn out of Insurance N (%)
AK**	<150	<30 (17.9)
CA	6,588	892 (13.5)
FL	10,779	2,529 (23.5)
HI	441	43 (9.8)
IN	767	125 (16.3)
KS	248	69 (27.8)
MA	1,001	50 (5.0)
MD	899	120 (13.3)
MN	356	60 (16.9)
MO	706	184 (26.1)
MT	333	55 (16.5)
NC	1,756	437 (24.9)
NM	3,454	382 (11.1)
NV**	<50	<10 (17.0)
OH	2,334	383 (16.4)
OR	10,374	2,041 (19.7)
RI	2,238	195 (8.7)
TX	137	66 (48.2)
WA	1,372	158 (11.5)
WI	894	132 (14.8)

*Sample included non-pregnant patients aged 19-64 without Medicare coverage who had a baseline insured visit between 2014 and 2017, with ≥3 ambulatory visits occurring within the subsequent 3-year period, and at least 12 months separating the first and last of these visits between 2014 and 2019. Those who churned were defined as having ≥2 consecutive uninsured visits. **Numbers <10 are masked to protect patients’ identities.

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Appendix Table 2.

Percent and Adjusted Odds of Insurance Churning Among Patients Seen in Community-Based Health Centers from 2014 to 2019* - Excluding 42,722 Patients with a Single Uninsured from Those Who Did Not Churn

	Total N = 257,436		Churned out of Insurance N = 39,542		Did not Churn out of Insurance N = 217,894		aOR of Churning (95% Cl)
	N	Col %	N	Row %	N	Row %	aOR of Churning (95% Cl)
Diabetes diagnosis
Yes	37,775	14.7	7,954	21.1	29,821	78.9	1.27 (1.19, 1.35)
No	219,661	85.3	31,588	14.4	188,073	85.6	Reference
Sex
Female	158,031	61.4	26,990	17.1	131,041	82.9	Reference
Male	99,405	38.6	12,552	12.6	86,853	87.4	0.76 (0.71, 0.82)
Age at baseline visit
19-44	143,124	55.6	21,819	15.2	121,305	84.8	Reference
45-64	114,312	44.4	17,723	15.5	96,589	84.5	0.85 (0.80, 0.90)
Race/Ethnicity
Non-Hispanic White	112,487	43.7	11,940	10.6	10,0547	89.4	Reference
Hispanic	81,149	31.5	16,986	20.9	64,163	79.1	1.93 (1.61, 2.31)
Non-Hispanic Black	38,512	15	7,742	20.1	30,770	79.9	1.85 (1.59, 2.16)
Non-Hispanic Other	12,019	4.7	1,183	9.8	10,836	90.2	0.85 (0.73, 0.98)
Missing	13,269	5.2	1,691	12.7	11,578	87.3	1.25 (1.09, 1.43)
Baseline payor type
Medicaid	165,417	64.3	22,863	13.8	142,554	86.2	Reference
Private	92,019	35.7	16,679	18.1	75,340	81.9	1.71 (1.49, 1.96)
Federal poverty level
≤138%	179,246	69.6	30,672	17.1	148,574	82.9	1.34 (1.19, 1.51)
>138%	47,195	18.3	6,662	14.1	40,533	85.9	Reference
Missing	30,995	12	2,208	7.1	28,787	92.9	0.56 (0.44, 0.73)
Patients’ residence
Rural	70,817	27.5	8,548	12.1	62,269	87.9	Reference
Urban	186,619	72.5	30,994	16.6	155,625	83.4	1.18 (0.92, 1.51)
Comorbidities excluding diabetes
Mental health disorder only	32,046	12.4	4,582	14.3	27,464	85.7	1.06 (0.98, 1.14)
Physical comorbidity only	65,421	25.4	12,009	18.4	53,412	81.6	1.16 (1.09, 1.23)
Mental health and physical comorbidity	37,704	14.6	5,741	15.2	31,963	84.8	0.98 (0.89, 1.08)
None	122,265	47.5	17,210	14.1	105,055	85.9	Reference
Mean ambulatory visits, (SD)	12.4	10.9	15.4	13.7	11.8	10.3	1.03 (1.02, 1.03)

Abbreviations: aOR, Adjusted odds ratio, CI, Confidence interval; SD, standard deviation.
*Sample included non-pregnant patients aged 19-64 without Medicare coverage who had a baseline insured visit between 2014 and 2017, with ≥3 ambulatory visits occurring within the subsequent 3-year period, and at least 12 months separating the first and last of these visits between 2014 and 2019. Those who churned were defined as having ≥2 consecutive uninsured visits. Those who did not churn included those who had every visit insured. Those with one uninsured visit among those who did not churn were excluded Chi-square tests for categorical variables and t-tests for continuous variables were used to test for differences between churning groups, except for age groups, all were significant at p < .001.
Bolded estimates are significant at p < .05.

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Appendix Table 3.

Percent and Adjusted Odds of Insurance Churning Among Patients With Diabetes Seen in Community-Based Health Centers from 2014 to 2019* - Excluding 42,722 Patients with a Single Uninsured from Those Who Did Not Churn

	Churned out of Insurance (N = 7,954)		Did not Churn out of Insurance (N = 29,821)		aOR of Churning (95% Cl)
	N	Row %	N	Row %	aOR of Churning (95% Cl)
Sex
Female	4,970	23.4	16,277	76.6	Reference
Male	2,984	18.1	13,544	81.9	0.78 (0.72, 0.85)
Age
19-44	2,421	21.6	8,782	78.4	Reference
45-64	5,533	20.8	21,039	79.2	0.88 (0.82, 0.94)
Race/Ethnicity
Non-Hispanic White	1,694	14.3	10,155	85.7	Reference
Hispanic	3,897	26.1	11,037	73.9	1.84 (1.51, 2.25)
Non-Hispanic Black	1,803	24.1	5,675	75.9	1.67 (1.41, 1.99)
Non-Hispanic Other	266	14.8	1,536	85.2	0.97 (0.81, 1.16)
Missing	294	17.2	1,418	82.8	1.21 (1.03, 1.43)
Baseline payor type
Medicaid	4,464	17.9	20,502	82.1	Reference
Private	3,490	27.2	9,319	72.8	2.00 (1.71, 2.33)
Federal poverty level
≤138%	6,354	22.3	22,091	77.7	1.37 (1.17, 1.59)
>138%	1,276	20	5,109	80	Reference
Missing	324	11	2,621	89	0.65 (0.42, 0.99)
Patients’ residence
Rural	1,566	18.3	6,970	81.7	Reference
Urban	6,388	21.8	22,851	78.2	1.14 (0.86, 1.51)
Comorbidities excluding diabetes
Mental health disorder only	310	19.3	1,298	80.7	0.99 (0.82, 1.20)
Physical comorbidity only	4,423	22.7	15,093	77.3	1.06 (0.97, 1.15)
Mental health and physical comorbidity	1,864	18.7	8,128	81.3	0.91 (0.81, 1.02)
None	1,357	20.4	5,302	79.6	Reference
Mean ambulatory visits, (SD)	19.5	15.7	16.4	12.2	1.02 (1.01, 1.02)
HbA1c control
≤9	5,343	19.4	22,168	80.6	Reference
>9	2,465	26.5	6,850	73.5	1.40 (1.30, 1.50)
Missing	146	15.4	803	84.6	1.12 (0.88, 1.43)
Diabetes medication regimen complexity
No medication	146	15.4	803	84.6	Reference
Lower complexity	4,874	21.3	1,7979	78.7	1.38 (1.26, 1.51)
High complexity	2,134	24.9	6,431	75.1	1.39 (1.23, 1.58)
Ever with insulin
Yes	3,496	23.5	11,411	76.5	1.05 (0.97, 1.13)
No	4,458	19.5	18,410	80.5	Reference
Acute complications during study period
0	6,614	20.5	25,713	79.5	Reference
1	807	25.7	2,327	74.3	1.19 (1.06 1.33)
≥2	533	23	1,781	77	0.97 (0.84, 1.13)

Abbreviations: aOR, Adjusted odds ratio, CI, Confidence interval.
*Sample included non-pregnant patients aged 19-64 without Medicare coverage who had a baseline insured visit between 2014 and 2017, with ≥3 ambulatory visits occurring within the subsequent 3-year period, and at least 12 months separating the first and last of these visits between 2014 and 2019. Those who churned were defined as having ≥2 consecutive uninsured visits. Those who did not churn included those who had every visit insured. Those with one uninsured visit among those who did not churn were excluded. Chi-square tests for categorical variables and t-tests for continuous variables were used to assess differences between churning groups, except for age groups, all were significant at p < .001.
Bolded estimates are significant at p < .05.