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    Views 5,265
    Original Investigation
    September 10, 2021

    Association of Medicaid Expansion With 5-Year Changes in Hypertension and Diabetes Outcomes at Federally Qualified Health Centers

    Author Affiliations
    • 1Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
    • 2Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 3Division of General Internal Medicine & Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
    • 4Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
    • 5Center of Innovation for Long-term Services and Supports, Providence VA Medical Center, Providence, Rhode Island
    JAMA Health Forum. 2021;2(9):e212375. doi:10.1001/jamahealthforum.2021.2375
    Key Points

    Question  What has been the 5-year association of Medicaid expansion with uninsurance rates, hypertension and diabetes outcomes, and racial and ethnic differences in outcomes in a national sample of federally qualified health centers (FQHCs)?

    Findings  In this cohort study using a difference-in-differences analysis of 946 FQHCs that serve 18.9 million patients per year, Medicaid expansion-state FQHCs experienced improved blood pressure and glucose control measures over 5 years overall and for Black and Hispanic patients compared with FQHCs in nonexpansion states. Expansion was also associated with sustained reductions in uninsurance at FQHCs.

    Meaning  The findings of this cohort study suggest that Medicaid expansion was associated with better 5-year health performance outcomes for FQHCs, which may be important for states that are considering Medicaid expansion.


    Importance  State decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown.

    Objective  To assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs.

    Design, Setting, and Participants  Using a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021.

    Exposures  Location in a state that expanded Medicaid eligibility as of 2014.

    Main Outcomes and Measures  Rates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity.

    Results  Of the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations.

    Conclusions and Relevance  In this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic populations. States considering Medicaid expansion may benefit from improved longer-run health measures for underserved patients with chronic conditions.