Abstract
Background:
Short- and long-term effects of COVID-19 will likely be designated preexisting conditions. We describe the prevalence of preexisting conditions among CHC patients overall, and those with COVID-19 by race/ethnicity.
Materials and methods:
This cross-sectional study used electronic health record (EHR) data from OCHIN, a network of 396 community health centers across 14 states.
Results:
Among all patients with COVID-19, 33% did not have a preexisting condition prior to the pandemic. Up to half of COVID-19-positive non-Hispanic Asians (51%), Hispanic (36%), and non-Hispanic Black (28%) patients did not have a preexisting condition prior to the pandemic.
Conclusions:
The future of the ACA is uncertain and the long-term health effects of COVID-19 are largely unknown, therefore ensuring people with preexisting conditions can acquire health insurance is essential to achieving health equity.
Introduction
Preexisting conditions are health conditions an individual has prior to health insurance enrollment.1 The Patient and Protection and Affordable Care Act (ACA) prohibits health insurance companies from denying coverage or charging higher premiums to patients with preexisting conditions.2 It is unclear if this provision will be upheld2 as the ACA continues to face the possibility of being dismantled. In March 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which cause COVID-19 started spreading across the United States (US). As of November 2020, the US reported >12 million cases.3 COVID-19 is associated with short- and long-term effects, therefore it will likely fit the definition of a preexisting condition.4 Some populations, such as medically underserved and racial/ethnic minorities, are at increased risk for COVID-19.5 Many of the populations at increased risk receive care in community health centers (CHCs), which serve 29 million US patients.6 We describe the prevalence of preexisting conditions among CHC patients overall and among those with COVID-19 by race/ethnicity.
Methods
This cross-sectional study used electronic health record (EHR) data from OCHIN, a network of 396 CHCs across 14 states. We assessed active patients aged 19–64 with ≥1 in-person visit between 1/1/2019–2/29/2020 (termed overall), and those with COVID-19 defined as patients with ≥1 positive test result or diagnosis code between 3/1/2020–10/10/2020. The outcome of interest was any preexisting condition as of 02/29/2020. Preexisting conditions1 were based on a modified version of the Kaiser Family Foundation (KFF) list of common “declinable medical conditions” maintained by more than half of insurers (see Table 1) and were identified by International Classification of Diseases, Ninth or Tenth Revision (ICD-9/10) codes. We conducted descriptive statistics to estimate the prevalence of preexisting conditions overall, and among those with COVID-19 by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic Asian, non-Hispanic other, and unknown). This study was approved by our Institutional Review Board.
Table 1.
Prevalence of one or more preexisting conditions among community health center patients aged 19–64 and among those positive for COVID-19 by race/ethnicity.
| Patients with a visit between 1/1/2019–2/29/2020 | Patients with COVID-19 (03/01/2020–10/10/2020)b | ||||
|---|---|---|---|---|---|
| % patients with preexisting conditionsa by 2/29/2020 | No. patients | % patients without preexisting conditionsa by 10/10/2020 | |||
| All patients | 61% | 7,532 | 33% | ||
| Hispanic | 55% | 4,391 | 36% | ||
| Non-Hispanic Asian | 44% | 244 | 51% | ||
| Non-Hispanic Black | 60% | 1,474 | 28% | ||
| Non-Hispanic Other | 68% | 72 | 21% | ||
| Non-Hispanic White | 71% | 1,004 | 22% | ||
| Unknown | 55% | 347 | 37% | ||
Preexisting conditions include HIV/AIDS; lupus; alcohol and drug abuse (excludes tobacco use); mental disorders (eg, depression, bipolar disorder); Alzheimer’s/dementia; multiple sclerosis; rheumatoid arthritis, fibromyalgia, and other inflammatory joint disease; muscular dystrophy; cancer other than skin; severe obesity; cerebral palsy; congestive heart failure; paraplegia and paralysis; coronary artery disease; Crohn’s disease and ulcerative colitis; Parkinson’s disease; chronic obstructive pulmonary disease, emphysema, and asthma; diabetes mellitus; pneumocystic pneumonia; epilepsy; hemophilia; sleep apnea; hepatitis; stroke; and kidney disease/renal failure. Preexisting conditions identified among patient with an in-person office visit between 1/1/2019–2/29/2020.
Patients with COVID-19 are those with a positive laboratory result in their EHR record or a COVID-19 diagnosis code.
Results
Among 784,332 adult CHC patients, 61% had at least one preexisting condition as of 02/29/2020. A greater percentage of non-Hispanic white patients had a preexisting condition compared to patients of other racial/ethnic categories (Table 1). Among patients with COVID-19 (N=7,532), 33% did not have a preexisting condition at the time of infection and we observed variability between race/ethnicity groups. Specifically, among patients with COVID-19, 51% non-Hispanic Asian, 36% Hispanic, and 28% non-Hispanic black did not have a preexisting condition.
Discussion
One in three CHC patients with COVID-19 did not have a preexisting condition prior to March 2020. We found a greater percentage of non-Hispanic Asian, Hispanic, and non-Hispanic black patients with COVID-19 had no prior preexisting conditions. Non-Hispanic Asian, Hispanic, and non-Hispanic black adults are facing the largest increases in unemployment,7 which also puts them at increased risk for losing employer-sponsored health insurance. Our findings highlight that minority patients would be most impacted if the ACA mandate differentiating coverage on the basis of preexisting conditions was altered or revoked and COVID-19 was designated a preexisting condition. Dismantling other provisions of the ACA (such as Medicaid expansion) could also lead to reduced access to health insurance and chronic disease management. These reductions will likely be worse for minority patients, especially those suffering from long-term COVID-19 effects. While 55% of all CHC patients had at least one preexisting condition prior to March 2020, nearly 65% of patients with COVID-19 had prior preexisting conditions supporting reports that patients with existing health problems are at increased risk for COVID-19.8 Our numbers could be underestimated as some patients may have undocumented chronic conditions or may have received a positive result for COVID-19 outside the OCHIN network. Although the future of the ACA is uncertain,2 it is clear that ensuring protection for patients with preexisting conditions is essential to achieving health equity.
Funding:
This work was supported by the National Cancer Institute (NCI) under Award Number P50CA244289. This program was launched by NCI as part of the Cancer Moonshot. This work was also supported by the Agency for Healthcare Research and Quality, grant number R01HS025962 and by the National Cancer Institute grant number R01CA204267 and by the National Heart, Lung, and Blood Institute grant number R01HL136575. The views presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies.
Footnotes
Conflict of interest: None.
Contributor Information
Nathalie Huguet, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.
Jennifer DeVoe, Department of Family Medicine, Oregon Health and Science University, Portland, Oregon.
References
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