The Impact of ACA Federal Funding Increases on Quality of Care and Service Use for Community Health Center Patients

Background: Community Health Centers (CHCs) are safety-net providers that provide access to comprehensive primary care services to 27 million low-income patients annually, the majority of whom are uninsured or publicly insured and from racial/ethnicity minority groups. To bolster the ability of CHCs to provide care to these patients, the Affordable Care Act (ACA) allocated $11 billion from 2011-2015 to expand CHC capacity, with an additional $3.6 billion extension for 2016-2017. However, there is little evidence about whether this funding improved quality outcomes or service use for CHC patients. Our objective was to assess the impact of funding increases on quality of care and service use for CHC patients.

Study sample: A 100% sample of all US health centers (n=1047 centers/year after exclusions), representing 20.1 million patients/year.

Methods: Using 2009-2017 CHC-level data from the Uniform Data System (UDS), we used a difference-in-differences (DID) framework combined with inverse probability of treatment weights (IPTWs) to estimate the effect of post-ACA increased federal funding per patient (below/above-median) on seven process measures (e.g. pap testing, colorectal cancer screening, pharmacologic treatment of asthma), three intermediate outcome measures (hypertension control, diabetes control, and birthweight), and 23 types of services (including preventive care, chronic disease management, and mental health and substance use services). For all outcomes, DIDs with IPTWs were calculated using generalized estimating equations with outcome-dependent specifications. We included a treatment indicator based on increased federal funding-levels/patient, a post-period indicator (2009-10 vs. 2011-17), an interaction between treatment status and post-period (the DID), a vector of time-variant confounders (percent patients uninsured, percent homeless, total patients/center, urban vs. rural location, Medicaid expansion status of state, EHR use, medical home recognition, non-federal grant funding/patient), and state and year fixed effects. Standard errors were clustered at the center-level.

Results: At baseline, CHCs receiving high levels of post-ACA federal funding, on average, had fewer patients, were more rural, had more uninsured patients, were located in states that did not expand Medicaid eligibility, and had worse quality outcomes. Preliminary results suggest that compared to similar CHCs receiving lower levels of federal funding following the ACA, those receiving higher levels of federal funding experienced relative improvements in 3 of 7 process measures, including pap testing (DID=3.1 percentage points, 95% CI 2.0-4.2); relative improvements hypertension control (DID=1.9 percentage points, 95% CI 1.1-2.7), especially for black patients (DID=2.6 percentage points, 95% CI 1.0-4.1); and relative increases in 16 of 23 service use measures, especially for mammograms, alcohol-related disorders, other substance use disorders, and anxiety (p<0.05 for all).

Conclusions: Increased federal funding to CHCs was associated with improved quality of care and service use. Sustaining CHC funding in future years may be important for improving outcomes and access to care for low-income patients, many of whom would otherwise be without access. More so, policymakers should be attentive to the fact that other policies resulting in reduced total revenue to CHCs, including reduced Medicaid eligibility and Medicaid block granting, may counteract these important gains in quality and capacity associated with the ACA funding increases.