Medicaid Expansion Associated With Higher-Quality Care in Community Health Centers

After the Affordable Care Act (ACA) allowed states to expand Medicaid eligibility for low-income residents, 25 states and the District of Columbia chose to do so by 2014. A team of researchers from Brown University analyzed data from federally funded community health centers and found increased levels of coverage and better care quality for those in Medicaid expansion states, according to their study published in Health Affairs.

The researchers examined data from 2011 through 2014 from 1057 community health centers funded by federal grants, 492 of which were located in states that had expanded Medicaid eligibility to non-elderly residents under 138% of the federal poverty level by January 2014. They hypothesized that the centers in these states would see increased proportions of patients with insurance coverage, a higher number of unique patients served, and improvements in care quality measures.

Unsurprisingly, the expansion states saw higher levels of Medicaid coverage and a corresponding decrease in uninsurance rates among their patients from 2011 to 2014. The uninsurance rates had decreased by 11.1 percentage points, and the Medicaid coverage rates saw an increase of 11.8 percentage points. Nonexpansion states saw steady levels of Medicaid coverage but increased rates of patients with private coverage compared to the expansion states. In 2014, about half of the patients at the centers in expansion states and 30% of those in nonexpansion states had Medicaid coverage.

From 2011 to 2014, the number of unique patients served at the community health centers climbed at a similar rate in both states that had expanded Medicaid and those that had not. The difference between increases in patients per center in expansion and nonexpansion states was not statistically significant.

The researchers also analyzed pre- and post-expansion performance on 8 quality measures: pharmacologic treatment of asthma, provision of lipid-lowering therapy for coronary artery disease, provision of aspirin for cardiovascular disease, adult body mass index (BMI) assessment, Pap testing, colorectal cancer screening, hypertension control, and diabetes control.

Health centers in expansion states showed significant improvements in quality for recommended asthma treatment, Pap testing, BMI assessment, and hypertension control, as compared to the centers in nonexpansion states. The differences for the 4 remaining quality measures were not statistically significant, but the direction of the correlation was positive for all but cardiovascular disease treatment.

When analyzing the difference in the 2 disease control measures by demographic factors, the researchers found that “the magnitude of improvement in hypertension control varied by race and ethnicity, with Hispanics experiencing nearly twice as much improvement as non-Hispanic whites.” Improvements in diabetes control were not significantly different for any racial or ethnic group.

The authors noted that the improvements in quality after expansion for Pap tests and hypertension control were driven by decreases in quality at health centers in nonexpansion states, indicating that refusing to expand Medicaid may lower the quality of care. They also pointed out that because baseline uninsurance rates were higher in nonexpansion states, these states could see even greater improvements in coverage and quality if they choose to expand Medicaid eligibility.

They called for further research into the effects of Medicaid expansion on healthcare quality, which is especially relevant as lawmakers prepare to repeal the ACA under the incoming Republican administration and potentially revoke Medicaid eligibility for the newly covered patients. Regardless of the ACA’s future, they wrote, “continued federal investment in community health centers remains critical to meeting the needs of the centers’ patient populations.”