Among CHC patients, we found that those with continuous Medicaid coverage and those who were uninsured sometime in the last year had similar levels of need for most types of care. However, patients reporting disruptions in insurance coverage had greater difficulty obtaining care compared to those with continuous Medicaid coverage.
CHC revenues from Medicaid reimbursement have grown post-ACA. In addition, the ACA created the Community Health Center Fund (CHCF), which provided $11 billion in mandatory funding for CHCs between 2011 and 2015 . These funds accelerated recent growth in the number of health center delivery sites, staffing, and service provision; between 2011 and 2016, the number of CHC sites grew by 50% and the number of patients served by 33% . The CHCF, which now comprises 70% of federal funding for CHCs, was recently reauthorized through the Bipartisan Budget Act of 2018, but only through 2019 .
All CHCs provide primary care services, with 89% providing mental health services, 81% providing dental services, and 35% providing substance use treatment in 2017 . However, uninsured and Medicaid patients seeking care at CHCs reported high levels of medical need and complexity, which necessitated referrals outside of the CHC. Those with gaps in coverage were significantly less likely to complete these outside referrals compared to those with continuous Medicaid coverage, with most uninsured patients citing the cost of care or lack of insurance as the reason. Although the survey did not collect information on the specific type of care needed, these referrals are likely to be for specialty care not provided in the CHC; forgoing such care may result in worse outcomes.
Notably, among those who were uninsured for some period in the last 12 months, nearly a quarter currently had Medicaid, but still faced greater difficulties accessing care compared to those with continuous Medicaid enrollment. In January 2018, the Centers for Medicare and Medicaid Services reversed guidance for Section 1115 waivers to allow states to impose work requirements as a condition for Medicaid eligibility. Fifteen states have submitted such waivers with seven approved as of April 2019 . Some states are also including other provisions, such as increasing cost-sharing requirements or stipulating lock-out rules, which could impact Medicaid eligibility and increase the number of enrollees with disruptions in coverage. Our findings suggest that policies that increase Medicaid churn or disruptions in coverage could result in greater barriers for obtaining needed medical care, even among those with access to safety net care at CHCs.
This study has limitations. This is a cross-sectional study and there could be unmeasured confounding, although we were able to adjust for a number of sociodemographic and health-related traits. The comparison groups were similar with respect to a number of key traits, including age, education, household income, and health and functional status; however, those with gaps in insurance coverage were more likely to speak a non-English language at home, live in rural areas, and have psychological distress, which could contribute to additional barriers in accessing care.
The survey also did not capture how long respondents had gaps in insurance coverage or the reason for their lapse in coverage. The HCPS sample includes CHC patients with at least one prior visit and may not be generalizable to those who use CHCs more sporadically. We were not able to link patient responses with information on CHC service availability or whether respondents were directly affected by Medicaid expansion. Lastly, reasons for having difficulty obtaining care were only available for incomplete referrals, but not the other types of care in the survey.