In 2014 many uninsured, low-income nonelderly adults gained access to health insurance in states that expanded Medicaid eligibility under the Affordable Care Act. Federally funded community health centers were likely to be particularly affected by this expansion because many of their patients were uninsured and low income. We used a difference-in-differences approach to compare changes among 1,057 such centers in expansion versus nonexpansion states from 2011 to 2014, in terms of their patients' insurance coverage, the number of patients they served, and the quality of care they provided. Medicaid expansion was associated with large increases (12 percentage points) in Medicaid coverage and corresponding declines (11 percentage points) in uninsurance rates. The numbers of patients served increased in both expansion and nonexpansion states, and the magnitude of increase did not differ significantly between the groups of states. Medicaid expansion was associated with improved quality on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control. This analysis suggests that states' decisions about Medicaid expansion have important consequences for health center patients, with expansion improving treatment and outcomes of chronic disease and bolstering the use of recommended preventive services.

IMPORTANCE State decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown. OBJECTIVE To assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs. DESIGN, SETTING, AND PARTICIPANTS Using a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021. EXPOSURES Location in a state that expanded Medicaid eligibility as of 2014. MAIN OUTCOMES AND MEASURESRates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity. RESULTSOf the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations. CONCLUSIONS AND RELEVANCEIn this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic (continued) Key Points Question What has been the 5-year association of Medicaid expansion with uninsurance rates, hypertension and diabetes outcomes, and racial and ethnic differences in outcomes in a national sample of federally qualified health centers (FQHCs)? Findings In this cohort study using a difference-in-differences analysis of 946 FQHCs that serve 18.9 million patients per yea...

Medicaid expansion had great potential to affect community health centers (CHCs), particularly in rural areas, because their patients are predominantly low income and disproportionately uninsured. Using data for 2011-15 on all CHCs, we found that after two years Medicaid expansion was associated with an 11.44-percentage-point decline in the share of CHC patients who were uninsured and a 13.15-percentage-point increase in the share with Medicaid. Changes in quality and volume were consistently observed in rural CHCs in expansion states, which had relative improvements in asthma treatment, body mass index screening and follow-up, and hypertension control, along with substantial increases in volumes for eighteen of twenty-one types of visits-particularly those for mammograms, abnormal breast findings, alcohol-related disorder, and other substance abuse disorder. Similar relative gains were not observed in urban CHCs in expansion states. Repealing or phasing out Medicaid expansion could reverse observed gains in quality and service use and could be particularly detrimental to low-income rural populations.

Objective: To describe social needs among low-income adults and estimate the relationship between level of unmet social needs and key indicators of health care access and quality.

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Introduction: Federally Qualified Health Centers serve 29.8 million low-income patients across the U. S., many of whom have unaddressed social risks. In 2019, for the first time, data on social risk screening capabilities were collected from every U.S. Federally Qualified Health Center. The objectives of this study were to describe the national rates of social risk screening capabilities across Federally Qualified Health Centers, identify organizational predictors of screening, and assess between-state heterogeneity.Methods: Using a 100% sample of U.S. Federally Qualified Health Centers (N=1,384, representing 29.8 million patients) from the 2019 Uniform Data System, the primary outcome was whether a Federally Qualified Health Center collected data on patients' social risk factors (yes/no). Summary statistics on the rates of social risk screening capabilities were generated in aggregate and by state. Linear probability models were then used to estimate the relationship between the probability of social risk screening and 7 key Federally Qualified Health Center characteristics (e.g., Federally Qualified Health Center size, Medicaid MCO contract, Medicaid accountable care organization presence). Data were analyzed in 2020-2021.Results: Most (71%) Federally Qualified Health Centers collected social risk data, with a betweenstate variation. The most common screener was the Protocol for Responding to and Assessing Patients' Assets Risks and Experiences (43% of Federally Qualified Health Centers that screened), whereas 22% collected social risk data using a nonstandardized screener. After adjusting for other characteristics, Federally Qualified Health Centers with social risk screening capabilities served more total patients, were more likely to be located in a state with a Medicaid accountable care organization, and were less likely to have an MCO contract.Conclusions: There has been widespread adoption of social risk screening tools across U.S. Federally Qualified Health Centers, but between-state disparities exist. Targeting social risk screening resources to smaller Federally Qualified Health Centers may increase the adoption of screening tools.

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