Background It is crucial to understand the impact of the Affordable Care Act (ACA). This study assesses changes in insurance status of patients visiting community health centers (CHCs) comparing states that expanded Medicaid to those that did not. Methods Electronic health record data on 875,571 patients aged 19 to 64 years with ≥ 1 visit between 2012 and 2015 in 412 primary care CHCs in 9 expansion and 4 nonexpansion states. We assessed changes in rates of total, uninsured, Medicaid-insured, and privately insured primary care and preventive care visits; immunizations administered, and medications ordered. Results Rates of uninsured visits decreased pre- to post-ACA, with greater drops in expansion (−57%) versus nonexpansion (−20%) states. Medicaid-insured visits increased 60% in expansion states while remaining unchanged in nonexpansion states. Privately insured visits were 2.7 times higher post-ACA in nonexpansion states with no increase in expansion states. Comparing 2015 with 2014: Uninsured visit rates continued to decrease in expansion (−28%) and nonexpansion states (−19%), Medicaid-insured rates did not significantly increase, and privately insured visits increased in nonexpansion states but did not change in expansion states. Conclusions Medicaid expansion and subsidies to purchase private coverage likely increased the accessibility of health insurance for patients who had previously not been able to access coverage.

Objective To: (1) compare clinic-level uninsured, Medicaid-insured, and privately-insured visit rates within and between expansion and non-expansion states prior to and after the ACA Medicaid expansion among the three cohorts of patient populations; and, (2) assess whether there was a change in clinic-level overall, primary care, preventive care visits, and diabetes screening rates in expansion versus non-expansion states from pre- to post-ACA Medicaid expansion. Methods Electronic health record data on non-pregnant patients aged 19–64 with ≥1 ambulatory visit between 01/01/2012–12/31/2015 (n=483,912 in expansion states; n=388,466 in non-expansion states) from 198 primary care community health centers (CHCs) were analyzed. Using difference-in-difference methodology, we assessed changes in visit rates pre- versus post-ACA among cohort of patients with diabetes, pre-diabetes, no- diabetes. Results Rates of uninsured visits decreased for all cohorts in expansion and non-expansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared to non-expansion states, especially among pre-diabetes patients (+71%). In non-expansion states, privately-insured visit rates more than tripled for pre-diabetes cohort and doubled for the diabetes and no-diabetes cohorts. Rates for glycosolated hemoglobin screenings increased in all groups with the largest changes among no diabetes (RR=2.26, 95% CI=1.97–2.56) and pre-diabetes cohorts (RR=2.00, 95% CI=1.80–2.19) in expansion states. Conclusion The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with pre-diabetes. These findings are important to consider when making decisions regarding altering the ACA.

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21–64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post-relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09–1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05–1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16–1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11–1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.