Post Affordable Care Act Evaluation

Study Overview
=================
Brief Summary
-----------------
This innovative study will measure the impact of Affordable Care Act-sponsored Medicaid expansions on access to and utilization of community health center (CHC) services. Building on the investigators prior work that developed a robust community-based research infrastructure within the OCHIN community health information network, the investigator will utilize linked electronic health record data from the OCHIN network of >400 CHC clinics in 8 states that expanded Medicaid coverage and 8 states that did not expand.

Detailed Description
-----------------
The Affordable Care Act (ACA) called for every state in the United States (US) to expand Medicaid coverage to individuals at ≤138% of the federal poverty level by 2014. In a 2012 legal challenge, the Supreme Court ruled that states were not required to implement the ACA-sponsored Medicaid expansion; thus (by December 31, 2014), only 27 states and the District of Columbia expanded Medicaid, while 23 states did not. Little is known about the impact of ACA-sponsored Medicaid expansions on access to and changes in receipt of healthcare services among vulnerable populations. Yet this knowledge is essential to informing deliberations in 'non-expansion' states regarding whether to expand their Medicaid programs, and will also be helpful to 'expansion' states eager to learn about the impact of their expansions. The natural experiment created by the Supreme Court decision to make expansion optional for states provides a unique opportunity to assess the extent to which Medicaid expansions improve access to healthcare for low-income patients and other vulnerable populations. The proposed project will be one of the first to examine changes in access to and receipt of healthcare services and to Medicaid expenditures following ACA Medicaid expansions among a large population of safety net clinic patients. The investigators will use electronic health record data (EHR) from the OCHIN practice-based research network, which serves >1 million patients in 442 community health centers (CHCs) in 8 expansion states and 8 non-expansion states. Moreover, using CHC data from the 8 expansion-states, the investigators will examine differences in utilization among patients gaining new Medicaid coverage (newly insured), as compared to those already insured by Medicaid (already insured), and those who remain uninsured (uninsured). Finally, the investigators will link EHR data from the 213 OCHIN clinics in Oregon to Medicaid administrative claims data to assess overall healthcare utilization (including care received outside of CHCs, such as hospitalization) and to compare Medicaid expenditures among newly insured individuals versus those already insured. The investigators will address the following specific aims: Aim 1: compare pre-post health insurance status, primary care, mental health, and dental visits, and receipt of preventive services, as well as changes in payer mix among OCHIN CHCs in states that did and did not expand Medicaid; Aim 2: Examine pre-post utilization of CHC services (including receipt of preventive services) by newly insured patients compared to already insured patients and uninsured patients; and, Aim 3: Measure pre-post Medicaid expansion changes in overall utilization of healthcare services and costs to the Oregon Medicaid program among newly insured compared to already insured. The findings from this project will be extremely relevant to policy and practice, informing further improvements in the US healthcare system to ensure access to healthcare for vulnerable populations.

Official Title
-----------------
Post Affordable Care Act: Evaluation of Community Health Centers

Conditions
-----------------
Chronic Disease

Intervention / Treatment
-----------------
* Other: Medicaid Expansion


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients in intervention and control states aged 20-64 Exclusion Criteria: Patients outside of age range 20-64

Ages Eligible for Study
-----------------
Minimum Age: 20 Years
Maximum Age: 64 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Medicaid Expansion States<br>Patients receiving care in community health centers in states that expanded Medicaid (intervention group) | Other: Medicaid Expansion<br>* There will be no direct intervention, but rather an observation of change based on whether a state expanded Medicaid or not<br>|
| Non Medicaid Expansion States<br>Patients receiving care in community health centers in states that did not expand Medicaid (control group) | Other: Medicaid Expansion<br>* There will be no direct intervention, but rather an observation of change based on whether a state expanded Medicaid or not<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Health Insurance Status | Health insurance status derived from EHR data and is primarily based on information collected at each visit | 24 months prior to Medicaid expansion vs 24 months post | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Healthcare service utilization | Number and type of internal services utilized | 24 months prior to Medicaid expansion vs 24 months post | 
| Preventive Service utilization | Number and type of preventive services received | 24 months prior to Medicaid expansion vs 24 months post | 
| Medicaid Expenditures | We will calculate the average pre-post expansion difference in total Medicaid expenditures. We will attach an expenditure for each service based on its average Medicaid Fee-For-Service reimbursement in the first year for those who were insured or uninsured pre or post expansion | 24 months prior to Medicaid expansion vs 24 months post | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
healthcare access, utilization, expenditures, preventive services