In the expansion states, there were CHCs with , patients and 2,, primary care visits. Nonexpansion states in our sample had a greater proportion of non-Hispanic black patients In all states, there were more female than male patients. There was no significant difference in the overall rate of primary care visits for any racial and ethnic group from before to after ACA Medicaid expansion data not shown. Rates of Medicaid-insured visits increased in expansion states for all racial and ethnic groups immediately after ACA Medicaid expansion, whereas no change was observed for Medicaid-insured visits for any racial and ethnic group in nonexpansion states.
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Rates of uninsured visits decreased for all racial and ethnic groups in both expansion and nonexpansion states; the declines were more immediate and pronounced in expansion states. For privately insured visits, the largest changes after expansion were seen in nonexpansion states where all 3 racial and ethnic groups had increases; privately insured visit rates among Hispanic patients continued to increase throughout the second year after ACA implementation, whereas they stabilized for the other 2 racial and ethnic groups Figure 1.
Rates of payment type for primary care visits by race and and ethnicity. Although all racial and ethnic groups had increases in Medicaid-insured visit rates after implementation, no group significantly increased more than the other groups, as evidenced by nonsignificant DD estimates. Changes in visit rates were similar between non-Hispanic black and non-Hispanic white patients on all outcomes Table 2.
In nonexpansion states, the rates of Medicaid-insured visits across racial and ethnic groups did not significantly change after implementation periods. The most notable changes in nonexpansion states were in private insurance visit rates: all racial and ethnic groups increased significantly after ACA implementation, with Hispanic patients utilizing CHCs with private coverage at 3.
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Our study showed the ACA Medicaid expansion contributed to sizeable decreases in uninsured CHC visit rates for all racial and ethnic groups, a finding that is consistent with previous research. For example, Hispanic patients maintained the highest uninsured visit rates, and the decline in uninsured visits was significantly less for this group than for non-Hispanic white and non-Hispanic black patients after Medicaid expansion. The most likely reason is only US citizens and legal residents are eligible for Medicaid coverage, and it is estimated that there are up to 6 million unauthorized Hispanic immigrants living in the United States as of Nonexpansion states did not see significant differences in Medicaid-insured visits for any racial and ethnic group.
Conversely, expansion states saw large increases in Medicaid-insured visits for all racial and ethnic groups. Yet, Hispanic patients continued to have the lowest rates of Medicaid-insured visits compared with non-Hispanic white and non-Hispanic black patients. This finding suggests that gaps in Medicaid coverage have continued for Hispanic patients, while the disparities have been reduced for non-Hispanic black patients. Privately insured visits increased for all racial and ethnic groups in nonexpansion states, whereas they remained mostly stable in expansion states.
This increase was most pronounced among Hispanic patients.
The sharper increase in privately-covered visits among Hispanic patients may suggest that fewer of these patients were eligible for Medicaid and thus sought private coverage to comply with the individual mandate. These results also suggest that health insurance marketplaces were effective in helping some patients find coverage. There is, however, a documented coverage gap wherein some individuals have incomes too high for Medicaid eligibility but too low for subsidized private coverage, with 3 million adults likely to remain uninsured in states that did not expand Medicaid.
For example, newly Medicaid-insured CHC patients received more smoking medication orders and quit smoking at higher rates than their counterparts who remained uninsured. Improving their ratio of insured to uninsured patients is especially important, because CHC patient populations tend to be sicker and more complex than non-CHC patients and because CHCs continue to care for more patients. Based on mounting evidence that health insurance plays a role in access to recommended health care, 9 , 11 , 42 , 45 , 46 our findings suggest equitable access, even in CHCs, depends on equality in health insurance coverage.
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As the future of the ACA is unknown, it is imperative that we understand its impact to date. Because some of the states in our sample are represented by only a few CHCs, our results may not represent postexpansion Medicaid experiences of all states or expansion status groups. We could not ascertain Hispanic origin eg, Mexican, Puerto Rican, etc , nor could we identify Hispanic patients who were not eligible for Medicaid coverage because of immigration status. The payer distributions in our study are different from other primary care settings, so additional research to determine whether similar progress was made in reducing racial and ethnic disparities in non-CHC settings is needed.
It is also possible that once insured, CHC patients left the safety net for private clinics. We adjusted our multivariable analysis to account for economic differences between expansion and nonexpansion states, yet unmeasured confounders could impact our results. In CHCs, the ACA Medicaid reform contributed to lower uninsured visit rates for all racial and ethnic groups, suggesting that the ACA is having its intended effect on expanding health insurance coverage to more patients.
Differences, however, in Medicaid-insured, privately insured, and uninsured visit rates in expansion compared with nonexpansion states and among racial and ethnic minority patients remain, indicating equity has not yet been achieved.
The authors acknowledge the significant contributions to this study that were provided by collaborating investigators in the Natural Experiments in Translation for Diabetes Study Two. The authors also acknowledge the participation of our partnering health systems. Disclaimer: The views presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies.
Search for Keyword: GO. User Name Password Sign In. Previous Section Next Section. Variables We assessed rates of uninsured, Medicaid-insured, and privately insured primary care visits in the periods after and before Medicaid expansion, overall and temporally, stratified by race and ethnicity.
Analysis We report demographic information for CHC visits from expansion and nonexpansion states by race and ethnicity. Demographic Characteristics In the nonexpansion states, there were CHCs with , patients and 1,, primary care visits Table 1. View this table: In this window In a new window. Rates of Payment Type for Primary Care Visits by Racial and Ethnic Groups — Rates of Medicaid-insured visits increased in expansion states for all racial and ethnic groups immediately after ACA Medicaid expansion, whereas no change was observed for Medicaid-insured visits for any racial and ethnic group in nonexpansion states.
View larger version: In this window In a new window. Figure 1 Rates of payment type for primary care visits by race and and ethnicity. Nonexpansion States In nonexpansion states, the rates of Medicaid-insured visits across racial and ethnic groups did not significantly change after implementation periods. Figure 2 Payment visit type after ACA implementation by race and ethnicity. Previous Section. Insurance status and access to urgent ambulatory care follow-up appointments. CrossRef Medline Google Scholar. Socioeconomic status and risk for substandard medical care.
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Wherry LR , Miller S. Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasi-experimental study. Their health care systems, their hospitals, their doctors' practices are being affected by the cost of providing a lot of care that doesn't get compensated due to un-insurance," Kellerman said. Eyre is now running his own tea shop in College Park, Md.
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