Private/Marketplace Insurance in Community Health Centers 5 Years Post-Affordable Care Act in Medicaid Expansion and Non-Expansion States

Abstract

Community health centers (CHCs) play an important role in providing care for the safety net population. After implementation of the Affordable Care Act, many patients gained insurance through state and federal marketplaces. Using electronic health record data from 702,663 patients in 257 clinics across 20 states, we sought to explore the following differences between Medicaid expansion and non-expansion state CHCs: (1) trends in private/marketplace insurance post-expansion, and (2) whether CHC patients retain private/marketplace insurance. We found that patients in non-expansion state CHCs relied more heavily on private/marketplace insurance than patients in expansion states and had increases in private/marketplace-insured visits from 2014 through 2018. Additionally, there appeared to be seasonal variation in private/marketplace-insured visits that were more pronounced in non-expansion states. While a greater percentage of patients in non-expansion states retained private/marketplace insurance than in expansion states, a greater percentage of those who did not retain it became uninsured. In comparison, a greater percentage of patients in expansion states who lost private/marketplace insurance gained other types of health insurance. CHCs’ ability to provide adequate care for vulnerable populations relies, in part, on federal grants as well as reimbursement from insurers: decreases in either could result in reduced capacity or quality of care for patients seen in CHCs.

1. BACKGROUND

After implementation of the Affordable Care Act (ACA), the number of uninsured individuals decreased by more than 40%.[1–3] About 40% of the reduction in the uninsured rate was due to marketplace subsidies.[4] Because not all states chose to expand Medicaid eligibility, the opportunity to purchase affordable health insurance coverage through state and federal health insurance marketplaces was thought to be especially important for low-income, uninsured individuals living in states that did not expand Medicaid eligibility.[5]

Since 1965, community health centers (CHCs) have provided care to underserved communities. Most patients seen in CHCs have an income below the federal poverty level, and prior to implementation of the ACA, about 35% were uninsured.[6, 7] Post-ACA, CHCs in expansion states saw large and immediate gains in Medicaid insured visits and reductions in uninsured visits.[2, 3] Reductions in uninsured visits were seen to a lesser extent in states that did not expand. The continued number of uninsured visits in non-expansion states may be due, in part, to that fact that marketplace premiums and cost sharing are unaffordable for many low-income individuals, even if subsidies are provided.[8] A recent report found that enrollment in marketplace insurance declined in both 2017 and 2018.[9] Another study examining marketplace attrition found dropout was highest among low-income households.[10]

While some studies have examined recent changes in marketplace enrollment, none looked at marketplace insurance in CHCs. Furthermore, few studies looked at who continued enrollment in marketplace insurance and who disenrolled. Understanding changes in marketplace insurance in CHCs is important to provide additional evidence of the impact of the ACA on low-income households. This information can offer policymakers more insight on the impact of the ACA to help guide its future, as many of its provisions have been threatened. Specifically, this study sought to: (1) explore whether the percentage of CHC visits paid for by private/marketplace insurance changed by expansion status; and (2) assess the percentage of CHC patients who retained private/marketplace insurance, became uninsured, or changed insurance from 2014 through 2018, comparing expansion and non-expansion states.

2. DATA AND METHODS

2.1. DATA SOURCE

Electronic health record (EHR) data from the Accelerating Data Value Across a National Community health center nEtwork (ADVANCE) clinical research network (CRN) was utilized. ADVANCE is one of nine PCORnet CRNs and is a multi-center collaborative network led by OCHIN, Inc.[11] CRN EHR data from partners are centrally collected and routinely standardized resulting in a robust longitudinal repository of clinical data for patients seen in these CHCs.[11] For this analysis we utilized data from OCHIN and Health Choice Network. The demographic profile of patients seen in ADVANCE CHCs mirrors that of national estimates from all CHCs.[12] We analyzed visits from 2014 through 2018 to primary care clinics and local health departments that were ‘live’ on their EHR system by 1/1/2014. This study was approved by the Oregon Health & Sciences University institutional review board.

2.2. STUDY POPULATION

We included patients 19–64 years of age throughout the study period, 1/1/2014 – 12/31/2018, who had at least two visits at an eligible CHC to be able to assess continuity of insurance. Visits paid for by workers compensation or automobile claims were excluded as they do not reflect a patient’s actual health insurance status and may inaccurately reflect changes in insurance type. We excluded women who were pregnant any time during the study period, patients with a Medicare financed visit as those under the age of 65 on Medicare have different health profiles, and patients with a visit paid for by private insurance from 2012 through 2013. As only 7% of encounters pre-ACA were privately insured, this allowed us to better approximate patients with health insurance obtained through state or federal marketplaces. There were 702,663 patients included in our study population, 398,771 from 14 states that expanded Medicaid and 303,892 from 6 states that did not. Visits in states that expanded their Medicaid program after 2014 were assigned expansion or non-expansion status based on the date the state expanded.[13] Expansion states included Alaska, California, Hawaii, Massachusetts, Maryland, Minnesota, Montana, New Mexico, Nevada, Ohio, Oregon, Rhode Island, and Washington. Non-Expansion states included Florida, Kansas, Missouri, North Carolina, Texas, and Wisconsin.

2.3. OUTCOMES

Our main dependent variables of interest were: (1) a dichotomous variable identifying patients who gained private/marketplace insurance (i.e., had at least one private/marketplace insured visit post-ACA) and (2) a 4-level categorical variable denoting what happened after their initial private/marketplace visit. Upon gaining private/marketplace insurance, those who: a) had private/marketplace insurance for all subsequent visits were defined as retaining private/marketplace insurance; b) were uninsured for all subsequent visits were defined as becoming uninsured; c) temporarily lost insurance and then regained private/marketplace insurance were defined as churning; or d) had all subsequent visits paid for by another insurer were defined as gaining other insurance.

2.4. STATISTICAL ANALYSIS

Our analyses were descriptive. We examined monthly trends in the proportion of CHC visits covered by private/marketplace insurance. We then explored differences in retaining, becoming uninsured, churning, and gaining other insurance. We compared all findings by Medicaid expansion status. This study used Stata 15.1.

2.5. LIMITATIONS

We defined patients as having private/marketplace insurance if their insurance provider was a private health insurance company. We were unable to determine whether that was employer-sponsored coverage, purchased insurance outside the marketplace, or purchased insurance through the marketplace. However most patients seen in CHCs with private insurance directly purchase an individual plan rather than having employer-sponsored coverage.[12, 14] Additionally, by excluding patients with private health insurance in 2012–2013, which accounted for 7% of all visits during that time, we can approximate those with marketplace insurance. The use of EHR data limits us from knowing whether patients received care outside a CHC once they gained insurance, previous research found the majority of patients continue to receive care in CHCs over time and attrition rates in CHCs are similar to those in studies using prospectively collected data.[15]

3. RESULTS

We found an increase in the proportion of total visits paid for by private/marketplace insurance in both expansion and non-expansion states from 2014 through 2018 (Figure 1). Throughout that time, CHCs in non-expansion states had a greater percentage of visits covered by private/marketplace insurance than those in expansion states. On average, the percent of visits covered by private/marketplace insurance was 13.2% higher in states that did not expand Medicaid than in states that did. The percent of CHC visits covered by private/marketplace insurance increased 9.2 percentage points in expansion states, from 3.0% in January 2014 to 12.2% in December 2018. During that same time period, it increased 24.7 percentage points, from 3.1% to 27.8%, in states that did not expand Medicaid (Figure 1).

FIGURE 1:

Percent of CHC visits covered by private/marketplace insurance in Medicaid expansion and non-expansion states: 2014 – 2018

There appeared to be a seasonal pattern to private/marketplace-insured visits that was more pronounced in non-expansion states (Figure 1). Except in the first year post-ACA, which peaked in August, this seasonal trend resulted in a large uptick in private/marketplace insured visits from January until April or May of each calendar year followed by a subsequent decline until the end of the year. Despite these cyclical patterns, the percentage of visits to CHCs covered by private/marketplace insurance continued to increase in both expansion and non-expansion states. Among patients seen in a study clinic from 2014 through 2018, 30.2% of CHC patients living in a non-expansion state had at least one private/marketplace-insured visit compared to 17.8% of patients in expansion states. Across all demographic groups, a greater percent of visits in non-expansion states were private/marketplace financed as compared to expansion states (Appendix).

Figure 2 shows the distribution of private/marketplace insurance retention at the patient level in expansion and non-expansion states. Despite having a smaller percentage of patients that retained private/marketplace insurance in expansion states than non-expansion states (59.6% vs. 67.0%, respectively), a greater percentage of patients in expansion states gained other insurance (12.4% vs. 5.2%) or only temporarily lost private/marketplace insurance (i.e., churn) (11.8% vs. 9.8%) than patients in non-expansion states (Figure 2). While a larger proportion of patients in non-expansion states retained private/marketplace insurance than those in expansion states, a greater percentage subsequently became uninsured before the end of the study period (10.9% vs. 7.1%).

FIGURE 2:

Retention and disenrollment from private/marketplace insurance in CHCs in Medicaid expansion and non-expansion states: 2014–2018

4. DISCUSSION

After implementation of the ACA, we found the percentage of visits to CHCs paid for by private/marketplace insurance increased in both expansion and non-expansion states. Yet, a greater percentage of visits to CHCs were paid for by private/marketplace insurance in non-expansion states than in expansion states. This is likely due to the fact that relatively more CHC patients in non-expansion states got private insurance because Medicaid expansion was not available to them. More patients enrolled in private/marketplace insurance in non-expansion states and retained private/marketplace insurance over time than patients in expansion states. However, among patients who did not retain private/marketplace insurance, more became uninsured in non-expansion states while more gained other insurance in expansion states.

We found a seasonal pattern in the proportion of all CHC visits covered by private/marketplace insurance throughout the study period. An increase in the percent of visits covered by private/marketplace insurance at the start of the calendar year followed by a decrease through the end of that year. This pattern was more pronounced in non-expansion states compared to expansion states. This seasonal pattern mirrors findings from another study in which seasonal, widespread attrition was found even among the lowest income households.[10] The study found evidence that patients may have timed their visits to coincide with when they had insurance, a pattern that may have implications on appointment availability and access at under-resourced CHCs. Research should be done to further explore these seasonal patterns to better understand how patients are purchasing and using private/marketplace insurance.

Penalties for not purchasing health insurance increased three-fold from 2014 to 2015 and doubled again in 2016. With efforts to undo the ACA, such as the removal of the individual mandate in early 2019 and the elimination of federal reimbursement for cost-sharing subsidies in 2017, there have been concerns about patients dropping out of the marketplace.[9, 16] Despite these concerns, studies found the marketplace has remained stable.[17] Tax credits available to households with incomes up to 400% FPL help make health insurance more affordable and seem to make those with subsidies less influenced by increasing premiums and less likely to move out of the federal marketplace.[9] However, those with marketplace insurance often still face unaffordable co-pays and deductibles, making it difficult to utilize services.[18–20] Additionally, as high-deductible health plans are now included in state and federal marketplaces and the potential to cut subsidies remains, there may be more patients unable to pay for the services they need which may translate to reduced care for patients, especially in non-expansion states.

CHCs in states that expanded Medicaid are more financially stable, able to provide expanded services and treatment, and better able to offer affordable care to their patients than CHCs in states that did not expand.[21] CHCs rely on revenue from Medicaid and grant funding, but they have also benefited financially from marketplace enrollment and the subsequent decrease uninsured visit rates.[6, 7] In non-expansion states, CHCs rely more heavily on grants than those in expansion states, are unable to see as many patients and may be limited in providing the same level or type of care as expansion states CHCs.[21] The ability of CHCs to continue providing comprehensive, quality care to all patients is threatened from multiple fronts: grant funding is unstable and continually up for renewal; attrition from the marketplace has the potential increase in uninsurance rates; the introduction of high-deductible health plans into the marketplace may render more patients underinsured; and state work requirements reduce access to Medicaid.

5. CONCLUSION

This study found that, despite some seasonal variation, there appears to be a steady increase in private/marketplace-insured visits among patients seen in community health centers. While almost one-third of visits to CHCs in states that did not expand Medicaid were paid for by private/marketplace insurance, a greater percentage of patients in non-expansion states who lost private/marketplace insurance subsequently became uninsured while a larger proportion of patients in expansion states gained other insurance.

Highlights.

• From 2014–2018, the percent of private/marketplace insured visits increased

• Seasonal trends in private/marketplace coverage were found

• Maintance of private/marketplace insurance varied by in expansion status

APPENDIX:

Percent of Total CHC Patients with ≥1 Private/Marketplace Insured Visit by Patient Characteristic and Expansion Status: 2014 – 2018