The Affordable Care Act: Changing Patient Landscapes of Health Care Safety Nets

Mark Freeman II.

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Abstract

            The Affordable Care Act (ACA) completely changed the patient landscape of health care safety nets with its signing into law in 2010 and full implementation in 2014­­. In particular, its expansion of Medicaid significantly shifted uninsured patient health care provider (i.e. hospitals and clinics) utilization, from emergency departments and free clinics, towards community health centers (CHC) and federally qualified health centers (FQHC). Yet major gaps in health care coverage persist due to states choosing not to expand Medicaid, exclusion of undocumented immigrants, and misunderstandings of the ACA. Health care safety net providers must understand their changing demographics and the needs of vulnerable uninsured patient populations. In doing so, health care safety net providers will be better informed with regards to implementing necessary changes for addressing the needs of patients in the post-ACA era, or with the possibility of the ACA’s removal by the current administration.

Introduction

The enactment of the Affordable Care Act has significantly reduced the number of uninsured Americans, yet those who do not qualify for coverage under the ACA still face many obstacles in obtaining necessary health care. Those without insurance must rely on health care safety nets, which are “locally organized [systems] of health care delivery intended to fill gaps in access to health care services for uninsured… and other vulnerable populations in medically underserved communities.”1 Health care providers within these systems include emergency rooms, community health centers, federally qualified health centers, and free clinics.1 These sites of care represent “providers of last resort” for undocumented immigrants, permanent immigrants who do not qualify for federal aid, and those whose income is over the threshold for Medicaid but not high enough to pay for health insurance.2

It is important to note the differences among these providers within the health care safety net. Each provider has different sources of funding that determine whom they can serve and which services they can provide—with a majority of providers relying on Medicaid for reimbursement. Under previous law (i.e., the Emergency Medical Treatment and Labor Act, EMTALA) emergency rooms must accept anyone regardless of citizenship and ability to pay. Due to their association with hospitals, emergency rooms offer the broadest spectrum of health care services but are also the most expensive sites of care. CHCs are “private, nonprofit organizations that directly or indirectly (through contracts and cooperative agreements) provide primary health services and related services to residents of a defined geographic area that is medically underserved.”3 Furthermore, it is important to note that some CHCs are designated as federally qualified health centers, allowing them to receive additional federal funding. This ability to receive enhanced reimbursements opens an avenue of access for uninsured individuals and undocumented immigrants. However, many undocumented immigrants do not utilize FQHCs due to required paperwork and fear of deportation.1,4,5 Finally, “[free] clinics are nonprofit community health care providers that offer care to low-income, uninsured, or underinsured patients at little or no charge to the patient.”1 The main difference between CHCs and free clinics is that free clinics rely on donations, volunteers, and pro bono health care services to operate.1 It is important to note that particular emphasis will be placed on free clinics and community health centers within this literature review.

With the enactment of the Affordable Care Act, access to health care has significantly expanded to cover many of those previously uninsured; yet those who are not eligible for coverage under the ACA still find limited access to health care. Free clinics and CHCs must adapt to new political environments and patient demographics. Although extensive and systematic research is limited, utilization of various case studies and analysis of national surveys can help safety net providers better understand their new patient population and inform future decisions to meet patient needs. This literature review will summarize key components of the ACA, with emphasis on Medicaid expansion, as well as highlight research findings regarding patient needs, the ACA’s impact on health care safety nets, and future recommendations for health care safety net providers.

The ACA and Medicaid Expansion

            Despite the United States being a wealthy industrialized nation, the country ranks low for many health indicators including preventable deaths before the age of 75, access to health care, and infant mortality.6 The goals of the ACA were to mitigate such problems by “improving the quality of health care… [, lowering] costs… [,] increasing access to health care, and… providing greater consumer protection in health care.”6 These goals were to be accomplished by providing no-cost preventive health care services, linking health care provider performance to pay, expanding Medicaid coverage for low-income individuals and families, and subsidizing health insurance for lower middle income individuals and families through regulated marketplaces. The most significant changes protect patients from denial of coverage due to pre-existing conditions and sudden severe illness.6

One of the most politically contested aspects of the ACA is the mandated expansion of Medicaid to include “adults under the age of 65 who earn [up to] 138% below the poverty line….”2 Unfortunately, the Medicaid expansion mandate was ruled unconstitutional by the U.S. Supreme Court in 2012, thus allowing states the choice to opt into Medicaid expansion.7,8 With 19 states choosing not to expand Medicaid, a huge health care “gap” has been created in which many Americans within these states cannot afford coverage despite meeting the federal qualifications for Medicaid.2 Thankfully, free clinics fill this “gap” by providing necessary health care services, showing their continued importance post-ACA.

Understanding Patient Needs

The “strongest predictors of safety-net use…” were “…being from a high poverty neighborhood…, being dually eligible for Medicare and Medicaid…, and being black… or Hispanic....”9 In addition, non-Medicaid insured adults made up 35% of primary care visits within safety-net clinics.9 These patient populations suffer disproportionately from chronic diseases, such as diabetes and hypertension, that require consistent primary care visits and medication use. With CHCs being required to operate within communities suffering from such health disparities, their continued use remains important post-ACA .9 Yet there are still populations that have limited access to CHCs, and must rely on free clinics or emergency departments. Such populations include immigrants who have not resided in the U.S. for more than five years to qualify for Medicaid, those who do not qualify for Medicaid and cannot afford insurance, and undocumented immigrants. To better understand how to meet the needs of these populations, additional nationally representative research on free clinics is necessary, as most studies focus on particular geographic locations and or clinics.10,11 This literature review highlights research conducted within Virginia, Rhode Island, and North Carolina.

            One of these studies found that free clinics were the only facilities available to those still uninsured who required management of chronic diseases within Richmond, Virginia.1 It is important to note that this study predominately focused on the implications of the ACA for Hispanic immigrants, though barriers to care could affect all immigrants. Barriers to care included language, lack of transportation, financial barriers, and bureaucratic barriers (e.g. needing government-issued identification to submit a form).1 In addition, lack of information and limited understanding of free or low-cost resources available to uninsured patients were described as major contributors to lack of care in multiple studies. For instance, 32% of uninsured individuals surveyed in Providence, Rhode Island lacked internet access—a main source of information regarding health insurance.11 Language barriers exacerbated immigrants’ inability to understand available options as well.

            From such studies, it is clear that undocumented immigrants are especially vulnerable post-ACA to lack of health care, due to their exclusion from the law. In addition, many of the above mentioned barriers also limit documented immigrants from obtaining information regarding their available resources. When documented immigrants finally meet the five-year eligibility requirement for Medicaid, they may still be uninformed of their options. Finally, due to inconsistent Medicaid expansion by states, many U.S. citizens do not qualify for Medicaid in the states where they live, even though they would qualify in other states. All of these factors, combined with barriers to properly informing the public of their health care options, result in misinformed use of the health care safety net. Informing the public is necessary for all health care safety net providers to reduce the financial burden placed on tax payer funded emergency departments, and provide reasonably priced primary health care to low income individuals.1,2,11

Impact of ACA on Health Care Safety Nets

            One of the most notable impacts of the ACA was the significant increase of Medicaid-covered patient visits in states that chose to expand Medicaid. Specifically, CHC visits by uninsured patients decreased by 40%. States that chose not to opt into Medicaid expansion continued to have high rates of uninsured patients within their CHCs. Furthermore, it is estimated that out of the adults currently uninsured in non-expanding Medicaid states, 42% of that population will continue to be uninsured due to their respective states’ political decisions. Thus, CHCs will remain widely utilized and necessary in handling both increases in Medicaid insured patients in Medicaid expanding states and the health coverage gap in non-expanding Medicaid states.7 It is also important to note that though coverage has significantly expanded, those who do qualify for insurance may still not utilize their coverage due to high out-of-pocket costs. Consequently, these patients may utilize less expensive clinics, such as CHCs, which would put further strain on the health care safety net. 9

            Furthermore, it is projected that “36-45 million individuals will still be uninsured by 2019,”8 many of whom will need to utilize free clinics for affordable care.8 Specific information regarding the impact of the ACA on free clinics is limited. One study examined the impact of the ACA on free clinics within North Carolina. It is important to note that North Carolina leads in the number of free clinics within a state and is a non-expanding Medicaid state.10 The authors found changing perceptions of the role of free clinics, illustrating the shortcomings of the ACA in regards to informing the public of available health care options. One fear amongst free clinic directors was that due to the perception that most individuals are now covered, essential donations and volunteerism may decrease for free clinics.10

            Finally, to afford Medicaid expansion, policy makers decided to significantly cut Disproportionate Share Hospital (DSH) programs, which fund reimbursements to hospitals for losses associated with uncompensated and underpaid care for low-income patients. In addition, the assumption that a majority of individuals would be insured through the marketplace or Medicaid allowed policy makers to believe that providers would not need to rely on DSH post-ACA. Cuts in DSH significantly reduced emergency rooms’ ability to serve uninsured patients in non-Medicaid expanding states. Thus, costs for uninsured patients seen in emergency rooms will fall on local tax payers and low-income families.12

Suggested Changes for Health Care Safety Net Providers

Most sources emphasized the need to formally integrate free clinics in the health care safety-net to work in conjunction with CHCs. The current lack of integration is partly due to how free clinics operate off private donations, non-federal grants, and volunteerism. Integration would mitigate discontinuities of care resulting from inconsistent Medicaid expansion, citizenship status, and other socioeconomic factors. Specific ways of mitigating discontinuities include allowing family wide access regardless of insurance or ability to pay, free access to health care during temporary insurance coverage transition gaps, and adopting business models that mix insured and uninsured patients (such as sliding scale fees utilized by FQHCs). Furthermore, transportation, housing, and free and or low-cost preventive care should be integrated with health services in the safety net—allowing further entry points into the health care system through either free clinics or CHCs.2,11,13,14

            Finally, health care safety net providers must play a role in educating the public in regards to available health care options post-ACA. Specifically, providers must address the needs of patients with language barriers by offering them educational programs focused on insurance options and navigating the types of health care services within the safety net.8 Through education, patients would hopefully have a better understanding of their health care options and use the health care safety net more efficiently.

Conclusion

            Though the Affordable Care Act (ACA) has significantly reduced the number of uninsured Americans, safety net providers remain essential for accessing health care—especially amongst vulnerable populations such as immigrants who do not qualify for coverage, and individuals who cannot afford out-of-pocket expenses for insurance. These shifts in coverage have greatly changed the patient landscapes of health care safety nets, most notably for CHCs within Medicaid expanding states and free clinics.

            Finally, since writing this literature review, the political context surrounding health care reform has changed dramatically with the new administration, and with Republicans controlling both the House of Representatives and the Senate. It remains unclear if the ACA will be repealed, or if there will be legislation to replace the ACA if it is repealed. Although the House passed the American Health Care Act, Republican Senators have been unable to secure the necessary votes to push forward the repeal and replacement of the ACA. Even with the uncertainty of the future of the ACA, the highlighted changes for health care safety net providers still hold merit, as they push for informed health care utilization by patients and further integration of free clinics within the safety net.

 

 

References

1. Liebert S, Ameringer CF. The Health Care Safety Net and the Affordable Care Act: Implications for Hispanic Immigrants. Public Administration Review. 2013;73(6):810–20.

2. Birs A, Liu X, Nash B, Sullivan S, Garris S, Hardy M, et al. Medical Care in a Free Clinic: A Comprehensive Evaluation of Patient Experience, Incentives, and Barriers to Optimal Medical Care with Consideration of a Facility Fee. Cureus. 2016;

3. Smith M, JH Bloomberg School of Public Health. The Johns Hopkins Primary Care Policy Center - Definitions [Internet]. Johns Hopkins Bloomberg School of Public Health. [cited 2016May3]. Available from: http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/definitions.html

4. Marrow HB, Joseph TD. Excluded and Frozen Out: Unauthorised Immigrants’ (Non)Access to Care after US Health Care Reform. Journal of Ethnic and Migration Studies. 2015;41(14):2253–73.

5. Ortega AN, Rodriguez HP, Bustamante AV. Policy Dilemmas in Latino Health Care and Implementation of the Affordable Care Act. Annu Rev Public Health Annual Review of Public Health. 2015;36(1):525–44.

6. Fitzgerald MP, Bias TK, Gurley-Calvez T. The Affordable Care Act and Consumer Well-Being: Knowns and Unknowns. Journal of Consumer Affairs. 2015;

7. Angier H, Hoopes M, Gold R, Bailey SR, Cottrell EK, Heintzman J, et al. An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act. The Annals of Family Medicine. 2015Jan;13(1):10–6.

8. Kamimura A, Tabler J, Chernenko A, Aguilera G, Nourian MM, Prudencio L, et al. Why Uninsured Free Clinic Patients Don’t Apply for Affordable Care Act Health Insurance in a Non-expanding Medicaid State. Journal of Community Health J Community Health. 2015;41(1):119–26.

9. Nguyen OK, Makam AN, Halm EA. National Use of Safety-Net Clinics for Primary Care among Adults with Non-Medicaid Insurance in the United States. PLOS ONE PLoS ONE. 2016;11(3).

10. Swan GA, Foley KL. The Perceived Impact of the Patient Protection and Affordable Care Act on North Carolina's Free Clinics. North Carolina Medical Journal. 2016Jan;77(1):23–9.

11. Pigoga J, Kibria F, Pinilla M, Bicki A, Joseph V, De Groot AS. Barriers to Health Insurance Pre- and Post-Affordable Care Act Implementation in Providence, RI. R I Med J (2013). 2015 Dec 1;98(12):35-9. PubMed PMID: 26623454.

12. Neuhausen K, Davis AC, Needleman J, Brook RH, Zingmond D, Roby DH. Disproportionate-Share Hospital Payment Reductions May Threaten The Financial Stability Of Safety-Net Hospitals. Health Affairs. 2014Jan;33(6):988–96.

13. Darnell JS. Free Clinics in the United States. Archives of Internal Medicine. 2010;170(11):946.

14. Hall MA. The Mission of Safety Net Organizations Following National Insurance Reform. Journal of General Internal Medicine. 2011;26(7):802–5.

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