Improving health care access for low-income patients in a mixed insurance market: investigating the impact of the U.S.’s Affordable Care Act on Federally Qualified Health Centers
Ercia, Angelo Amparo
Background: The Affordable Care Act (ACA) aimed to enhance access to health care in the United States, particularly for those without comprehensive insurance. This thesis examines the impacts of the ACA on equity of access by investigating its effect on Federally Qualified Health Centers (FQHCs). FQHCs provide essential primary care to low-income people. Their experiences of providing primary care during the period of the ACA’s implementation can provide valuable information about the challenges of addressing inequities of access in the context of a dual insurance market. Aim: To examine the ACA’s impact on the ability of FQHCs in Arizona, California, and Texas to provide essential primary care to people with limited health care access. Methods: Using a case study approach, the thesis draws on two data sources to contextualize and explore how the ACA was perceived to impact on FQHCs in Arizona, California, and Texas, and how senior FQHC staff responded to these impacts. Data from Uniform Data System (UDS) were analyzed to ascertain trends in overall population insurance coverage and in FQHCs’ patient coverage, provided services, and funding sources in Arizona, California, and Texas from 2008 to 2015. The main body of the research focused on administrators’ experiences of the ACA’s impact on FQHCs and their ability to meet the needs of their patients. This was explored via 23 interviews with executive directors and mid-level managers from 10 FQHCs in the three states, which took place between July and September 2015. Results: Impact on FQHCs: FQHCs in Arizona and California experienced an increase in the proportion of their patients covered by Medicaid following implementation of the ACA. Interviews confirmed that Medicaid expansion in Arizona and California enabled many uninsured patients to obtain coverage and access to care, with FQHCs experiencing increases in demand and revenue. In contrast, FQHC administrators in Texas believed the ACA had minimal impact on both patient coverage and revenues, as the state had not expanded Medicaid. FQHCs in Texas experienced a minimal increase in the proportion of patients with insurance coverage, with most newly insured patients gaining coverage via the private market. UDS data from 2008-2015 showed that FQHCs in all three states experienced an increase in real income from federal grants under the ACA. Response of FQHCs: The majority of key informants in Arizona and California stated the ACA had enhanced their ability to serve their patients, primarily due to increased revenue from Medicaid which enabled FQHCs to increase their capacity and better respond to the needs of their patients. In contrast, there was no consensus among administrators in Texas regarding the impact of the ACA on their ability to serve their patients. The absence of Medicaid expansion and weaknesses of private insurance meant patients in Texas faced particular difficulty in accessing care due to high deductibles, the limited depth of coverage and a small pool of willing providers. Discussion and conclusions: The experience of FQHC administrators provides a valuable lens through which to evaluate the effectiveness of the ACA in terms of one of its core objectives: addressing inequities of health care coverage and access in the U.S. After the legislation took effect, FQHCs in Arizona and California experienced considerable improvements in their ability to meet patient needs, especially due to the expansion of Medicaid in these states. In contrast, FQHCs in Texas did not experience a notable improvement in their ability to serve their patients. The FQHCs in all three states continued to face challenges in securing their patients’ access to specialist health services. The findings of this thesis highlight the scale of challenge faced by policymakers that seek to expand health care access within a context of mixed public/private insurance. While the ACA aimed to improve health care access by expanding coverage, its ability to do so was compromised by: i) regulatory barriers to the expansion of public health insurance (a legal challenge and Supreme Court ruling meant half of all US states opted out of Medicaid expansion); ii) limitations in coverage and access associated with private health insurance; and iii) reluctance on the part of some healthcare providers to accept patients with public or more limited private insurance.