A driving force for health equity

Recently Published Study Investigates How ACA Has Impacted Insurance Enrollment and CHC Utilization

When the Affordable Care Act (ACA) was passed nearly 10 years ago, 43 million Americans were without health insurance. The landmark legislation introduced health insurance marketplaces and Medicaid expansion that has caused the number of uninsured Americans to fall to 27 million in 2019.

A recent study by OCHIN and OHSU researchers published in the Annals of Family Medicine investigates how the bill has impacted insurance enrollment and community health center (CHC) utilization. The study, which followed over 130,000 uninsured patients before and after the passage of the ACA insurance expansions, found that nearly 21% of CHC patients are still uninsured and have more than one diagnosed health condition. While access to care and benefits have expanded, many people seeking health care coverage are still not able to access it, making CHCs essential providers even after the passage of the ACA.

Using the ADVANCE Collaborative database, researchers from OCHIN and OHSU were able to track uninsured patient visits to CHCs before and after the expansion of the ACA in 11 states between 2012 and 2015. Almost 30% of uninsured patients registered for either Medicaid (15%) or other insurance (13%) after the law went into effect. More than 20% of patients remained uninsured after the ACA expansion, and more than 50% of patients who had a visit before the ACA did not have a visit after, suggesting there are still systemic barriers to coverage, as the uninsured population were disproportionately Hispanic, low-income, and under the age of 35 in this sample. Though the ACA increased the number of patients with health insurance in this sample, researchers speculate enrollment is not higher due to the complex process of determining eligibility and obtaining health insurance.

In addition to insurance enrollment data, this study also followed patients’ use of ambulatory services before and after the ACA. The introduction of ambulatory visits is new for this kind of research and could lend critical insight into how patients make medical decisions based on affordability. This study found that those who gained insurance following passage of the ACA insurance expansions were more likely to use ambulatory care services, and those continuously uninsured used ambulatory care services less in the years after the ACA. Further study is needed to confirm these findings, but the evidence strongly supports the conclusion that uninsured people are not using ambulatory care services because of the high costs that are often unspecified at the time of treatment. This points to the need for continued campaigns for preventive care to treat conditions before becoming expensive emergencies, and the reality that families are still avoiding critical care because of their income level.

Results from the study prompted researchers to suggest that policy makers could focus on simplifying enrollment for health insurance, expanding insurance options, and removing barriers to care to reduce the strain on CHCs.

Read the full study published in the Annals of Family Medicine, and please contact Megan Hoopes (hoopesm@ochin.org) with any questions.