The Effect of Health Insurance Coverage on Access to Care for Community Health Center Patients

Background: Community Health Centers (CHCs) provide access to primary care services to 24 million patients annually, nearly all of whom are low-income and uninsured or publicly insured. While CHCs provide access to preventive services, chronic disease management services, and some behavioral services, for instance, specialty care is often obtained through referral, including that for behavioral health, and prescription drugs may be unaffordable to uninsured patients. Ensuring access to primary care is essential, as supported by $11 billion in ACA funding to expand CHC capacity. However, to the extent that primary care providers refer patients outside of the CHC, recommend follow-up care, or write prescriptions not provided at a discounted price, if patients cannot access these downstream services because of lack of insurance, then increased access to primary care alone will do little to impact health outcomes for these patients.

Objective: To estimate the effect of having health insurance coverage on access to necessary medical care, specialty care, behavioral health care, recommended follow-up care, and medications for patients served by community health centers.

Methods: We used a nationally representative sample of 5,040 non-elderly adult CHC patients from the 2014 HRSA Health Center Patient Survey, representing 13.9 million patients. We examined 19 patient-reported outcomes related to access to and delayed access to medical care (any), specialty care, behavioral health care, follow-up care after abnormal cancer screenings, any medications, and medications for hypertensive, asthmatic, diabetic, and hyperlipidemic patients. For each outcome, we calculated inverse probability of treatment weights (IPTWs) based on propensity scores to estimate average treatment effects, where patients with insurance were considered treated. Propensity scores included 20 patient-level sociodemographic and clinical covariates. Weights were stabilized to a mean of one and truncated at the 99th percentile. We used logistic regression models with IPTWs to estimate the effect of having health insurance on each outcome. Models used robust variance estimators and directly adjusted for covariates included in the propensity score model; thus, we produced doubly robust estimates.

Results: In 2014, having health insurance coverage was associated with better access to most types of care examined. For instance, compared to statistically similar health center patients without insurance, patients with insurance coverage were more likely to have access to necessary medical care (aOR=2.12, 95%CI 1.74-2.58); to see a recommended specialist (aOR=2.73, 95%CI 2.15-3.46); to see a mental health professional if advised (aOR=1.74, 95%CI 1.31-2.32); to receive recommended follow-up care after an abnormal pap (aOR=3.44, 95%CI 1.80-6.54); and to get necessary prescription medications (aOR=2.10, 95%CI 1.75-2.53), particularly for patients with high cholesterol (aOR=2.25, 95%CI 1.48-3.43). Insurance was not associated with access to condition-specific medications for hypertensive, asthmatic, or diabetic patients.

Discussion and conclusions: Results highlight the vital role of health insurance in accessing care within the safety-net, particularly for non-primary care services. This is especially important in light of potential reversals to Medicaid expansion, as health centers may not be able to fully compensate for resulting losses in patient insurance coverage. Furthermore, expanding safety-net capacity to provide non-primary care services for uninsured patients remains critical.