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 Information | Unadjusted Visit Rate | Covariate Adjusted Visit Rate | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Nonexpansion State | Expansion State | Nonexpansion State | Absolute Rate Difference | Expansion State | Absolute Rate Difference | |||||
| Pre-ACA | Post-ACA | Pre-ACA | Post-ACA | Pre-ACA | Post-ACA | Pre | Post | |||
| Uninsured | ||||||||||
| Diabetes | 61.2 | 52.0 | 75.3 | 33.2 | 43.2 | 36.7 | −6.5 | 63.1 | 27.8 | −35.3 |
| Prediabetes | 52.6 | 45.1 | 52.4 | 25.2 | 39.8 | 34.1 | −5.7 | 50.1 | 24.1 | −26.0 |
| No diabetes | 30.2 | 24.6 | 31.4 | 14.7 | 27.6 | 22.5 | −5.1 | 37.2 | 17.4 | −19.8 |
| Medicaid | ||||||||||
| Diabetes | 37.4 | 37.1 | 80.0 | 125.6 | 35.8 | 35.5 | −0.3 | 62.7 | 98.4 | 35.7 |
| Prediabetes | 29.4 | 31.4 | 70.4 | 120.0 | 27.9 | 29.9 | 2.0 | 48.9 | 83.5 | 34.6 |
| No diabetes | 15.0 | 15.0 | 31.7 | 50.6 | 20.6 | 20.5 | −0.1 | 36.5 | 58.3 | 21.8 |
| Privately insured | ||||||||||
| Diabetes | 9.7 | 26.9 | 34.0 | 37.5 | 16.0 | 44.2 | 28.2 | 19.2 | 21.2 | 2.0 |
| Prediabetes | 9.9 | 31.5 | 31.3 | 34.5 | 18.0 | 57.0 | 39.0 | 20.2 | 22.3 | 2.1 |
| No diabetes | 4.7 | 12.6 | 18.4 | 19.5 | 12.0 | 32.3 | 20.3 | 14.5 | 15.4 | 0.9 |
| Other public | ||||||||||
| Diabetes | 36.4 | 28.8 | 39.9 | 43.2 | 47.7 | 37.7 | −10.0 | 21.6 | 23.4 | 1.8 |
| Prediabetes | 28.7 | 24.1 | 26.9 | 28.0 | 48.3 | 40.5 | −7.8 | 15.8 | 16.4 | 0.6 |
| No diabetes | 13.2 | 9.7 | 7.8 | 7.0 | 29.6 | 21.7 | −7.9 | 6.1 | 5.5 | −0.6 |
| Total Visits | ||||||||||
| Diabetes | 144.8 | 144.8 | 229.2 | 239.5 | 169.9 | 169.9 | 0.0 | 177.8 | 185.8 | 8.0 |
| Prediabetes | 120.6 | 132.1 | 181.0 | 207.7 | 148.8 | 163.0 | 14.2 | 140.2 | 160.9 | 20.7 |
| No diabetes | 63.1 | 61.9 | 89.3 | 91.9 | 99.1 | 97.2 | −1.9 | 90.9 | 93.6 | 2.7 |
| Primary care visits | ||||||||||
| Diabetes | 122.6 | 120.6 | 190.1 | 195.8 | 132.9 | 130.7 | −2.2 | 140.7 | 144.9 | 4.2 |
| Prediabetes | 103.6 | 111.6 | 152.8 | 173.6 | 120.9 | 130.2 | 9.3 | 118.0 | 134.1 | 16.1 |
| No diabetes | 54.8 | 52.7 | 75.4 | 76.6 | 90.8 | 87.4 | −3.4 | 86.2 | 87.7 | 1.5 |
| Preventive care visits | ||||||||||
| Diabetes | 4.7 | 5.9 | 4.1 | 4.6 | 6.6 | 8.3 | 1.7 | 2.9 | 3.2 | 0.3 |
| Prediabetes | 7.0 | 9.4 | 5.2 | 6.8 | 10.2 | 13.8 | 3.6 | 4.5 | 5.9 | 1.4 |
| No diabetes | 5.8 | 7.0 | 4.6 | 5.1 | 9.9 | 11.9 | 2.0 | 4.3 | 4.7 | 0.4 |
| Glucose testing | ||||||||||
| Diabetes | 67.4 | 81.9 | 76.6 | 87.6 | 65.4 | 79.5 | 14.1 | 78.2 | 89.5 | 11.3 |
| Prediabetes | 36.3 | 45.0 | 35.8 | 44.2 | 33.9 | 42.0 | 8.1 | 35.3 | 43.6 | 8.3 |
| No diabetes | 12.2 | 14.7 | 11.1 | 14.3 | 18.5 | 22.3 | 3.8 | 19.3 | 24.8 | 5.5 |
| HbA1c screening | ||||||||||
| Diabetes | 52.3 | 76.3 | 65.5 | 82.7 | 53.8 | 78.4 | 24.6 | 70.9 | 89.5 | 18.6 |
| Prediabetes | 16.0 | 28.0 | 10.2 | 20.3 | 14.4 | 25.3 | 10.9 | 10.4 | 20.7 | 10.3 |
| No diabetes | 2.6 | 4.3 | 1.3 | 3.0 | 3.2 | 5.5 | 2.3 | 2.3 | 5.2 | 2.9 |
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.