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How are free & charitable clinics faring under the Affordable Care Act?
JULIE DARNELL, ASSOCIATE PROFESSOR, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF ILLINOIS AT CHICAGO
LINDSAY O’BRIEN, ASSOCIATE DIRECTOR, U.S. PROGRAMS, AMERICARES
143R D APHA ANNUAL MEETING & EXPO, NOVEMBER 2, 2015, CHICAGO, ILWe gratefully acknowledge support from the General Electric Foundation.
What are free & charitable clinics?
bills third-party payer
• 501(c)(3) entities• Target care to uninsured and/or underserved patients• Provide medical, dental, mental/behavioral health, medications• Utilize volunteers • Don’t bill third-party payers
Provides all goods and services at no charge, but may request donations
Provides goods & services for a fee
Charitable ClinicFree Clinic
Hybrid Clinic
Scope of the Free Clinic Sector ~ 1,000 free clinics in 2005-2006 Collectively served nearly 2 million mostly uninsured patients annually Provided 3.5 million medical and dental visits
Source: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.
Newly Insured 22.8 million gained coverage between 9/2013 to 2/2015
◦ 9.6 million in employer-sponsored plans◦ 6.5 million in Medicaid plans◦ 4.1 million in individual marketplace◦ 1.2 million nonmarketplace individual plans◦ 1.5 million in other plans
5.9 million lost coverage 16.9 million (net) newly insured
Source: Carman, K. G. Trends in Health Insurance Enrollment, 2013-15, Health Affairs, v. 34, no. 6, June 2015, p. 1044-1048. [RAND STUDY]
Uninsured
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 20250
5
10
15
20
25
30
35
40
45
50
35
2927 27 26 26 26 26 27 27 27
Mill
ions
Source: Congressional Budget Office. 2015. Insurance Coverage Provisions of the Affordable Care Act—CBO’s March 2015 Baseline.
NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT**
MO
MS
MN
MI*MA
MD
ME
LA
KY KS
IA*
IN* IL
ID
HI
GA
FL
DC
DE
CT
CO CA
AR*AZ
AK
AL
Adopted (31 States including DC)
Adoption Under Discussion (1 State)
Not Adopting At This Time (19 States)
Current Status of Medicaid Expansion Decisions
Research Question and Hypotheses
Research Question: How are free & charitable clinics faring under the Affordable Care Act?Hypothesis 1: Clinics located in states that have expanded Medicaid are faring worse than clinics located in non-expansion states.
Hypothesis 2: Clinics located in states that have expanded Medicaid are more likely to have made changes to their clinic operations than clinics in non-expansion states.
AmeriCares Emergency response and global health organization whose mission is to improve health and save lives in communities affected by disaster and in those with limited resources
Model:◦ Product donations from more than 200 corporations◦ Service delivery through local health care partners◦ Leverage: for every $1 donated, AmeriCares provides $20 in aid
METHODS
Survey Who: Free and charitable clinic partners of AmeriCares What:
◦ Organizational characteristics◦ Levels of funding and in-kind support◦ Fundraising efforts◦ Staffing and volunteer levels◦ Changes to operations (clinic, patients, services)
When: October-November 2014 How: Web-based survey
RESULTS
Response Rate 156 out of 355 eligible clinic partners (43.9%)
Characteristic Odds ratio 95% CI p-valueWeekly hours .992 .979, 1.005 .223Budget .999 .999, 1 .048# Volunteers .999 .998, 1.002 .987# Paid staff 1.050 .998, 1.104 .058# Patients .999 .999, 1.000 .069# Patient visits 1.000 .999, 1.000 .346Medicaid expansion state 1.421 .901, 2.241 .130
Logistic regression of non-response
Notes: dependent variable = non-response to survey; n=339; CI=confidence interval.
AmeriCares Sample Characteristics
Characteristic Total(n=355)
Respondent(n=156)
Nonrespondent(n=199)
p-value
Mean weekly hours open (n=341)
29 28 30 .285
Mean annual budget (n=347) $620,929 $539,278 $684,576 .263Mean # of volunteers (n=345) 130 130 129 .939Mean # of paid staff (n=340) 7.7 7.8 7.7 .906Mean # of patients (n=347) 1,900 1,742 2,024 .278Mean # of patient visits (n=347) 6,007 5,991 6,019 .976% in Medicaid expansion state (n=355)
37.2 40.4 34.7 .269
Notes: We tested differences in means between respondents and nonrespondents with the t-test and differences in categorical variables with the chi-square test. Tests of significance were two-tailed. We performed statistical analyses with Stata (ver 14).
Hypothesis #1: Faring Worse in Expansion States
Trends in Funding: Fundraising
Harder to raise $ No change Easier to raise $ Don't know0
10
20
30
40
50
60
70
80
90
100
59.7
25.8
4.89.7
42.4
0
46.7
10.9
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.009
Differences are statistically significant.
Trends in Funding
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
41.3 46
12.7
37.649.5
12.9
Decrease in FundingMedicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
Mean decrease0
10
20
30
40
50
60
70
80
90
100
20.8 22.4
Mean Percentage Decrease
Medicaid expansion stateNon expansion state
Perc
enta
ge
p-value=.896
Differences are NOT statistically significant.
p-value=.710
Trends in In-Kind Support
Decreased No change Increased Don't know0
10
20
30
40
50
60
70
80
90
100
38.142.9
6.412.7
19.6
64.1
3.3
13
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.031
Differences are statistically significant.
Trends in Staffing: Paid Positions
Decreased No change Increased Don't know
0102030405060708090
100
22.6
64.5
11.31.6
12.1
76.9
5.5 5.5
# of Paid PositionsMedicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
Decreased No change Increased Don't know
0102030405060708090
100
21
62.9
14.51.6
9.9
79.1
6.6 4.4
Hours of Paid Positions
Medicaid expansion stateNon expansion state
Perc
ent o
f clin
icsp-value=.102
Differences are NOT statistically significant.
p-value=.053
Trends in Staffing: Volunteer Medical Positions
Decreased No change Increased Don't know
0102030405060708090
100
31.8
57.1
11.10
14
76.3
7.5 2.2
# of Volunteer PositionsMedicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
Decreased No change Increased Don't know
0
10
20
30
40
50
60
70
80
90
100
36.5
52.4
11.110
19.4
71
7.5 2.5
Hours of Volunteer PositionsMedicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
p-value=.018
Differences are statistically significant.
p-value=.035
Trends in Scope of Services
Decreased No change Increased Don't know0
10
20
30
40
50
60
70
80
90
100
12.7
50.8
34.9
1.67.5
81.7
9.7 10.9
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.000
Differences are statistically significant.
Trends in Patient Volume: Patients & Visits
De-creased
No change
Increased Don't know
0
10
20
30
40
50
60
70
80
90
100
49.2
28.615.8
6.4
22.2
37.830
10
# Unduplicated PatientsMedicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
Decreased No change Increased Don't know
0
10
20
30
40
50
60
70
80
90
100
48.4
27.417.7
6.5
2538
30.4
6.5
# Patient VisitsMedicaid expansion stateNon expansion state
Perc
ent o
f clin
icsp-value=.005
Differences are statistically significant.
p-value=.024
Hypothesis #2: More Organizational Changes in Expansion States
Operational Changes: Organizational Delivery Model
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
38.7
58.1
3.211
83.5
5.5
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.000
Differences are statistically significant.
Operational Changes: Billing Model
Yes No Don’t know0
10
20
30
40
50
60
70
80
90
100
31.8
65.1
3.2
15.2
83.7
1.1
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.018
Differences are statistically significant.
Operational Changes: Clinic Flow
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
50.8 47.6
1.6
17.4
79.4
3.3
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.000
Differences are statistically significant.
Operational Changes: Technology Integration
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
38.3
60
1.7
18.7
79.2
2.2
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.000
Differences are statistically significant.
Operational Changes: Type of Data Collected
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
52.645.6
1.8
23.6
74.2
2.3
Medicaid expansion state Non expansion state
Perc
ent o
f clin
ics
p-value=.001
Differences are statistically significant.
Organizational Changes: Closure
Yes No Don't know0
10
20
30
40
50
60
70
80
90
100
8.1
90.3
1.66.5
85.8
7.6
Considered Closing
Medicaid expansion stateNon expansion state
Perc
ent o
f clin
ics
p-value=.290
Differences are not statistically significant.
Of the 8% (13 clinics) that “considered closing,” none reported actually planning to close
DISCUSSION
Hypothesis 1 Statistically significant differences between Medicaid expansion and non-expansion states in:◦ fundraising, in-kind support, # of volunteer medical positions,
# of patients, # of patient visits
No statistically significant differences in funding levels or in # of paid positions
Statistically significant differences in scope of services opposite hypothesized
Discussion of Hypothesis #1 Greater resource constraints facing clinics in expansion states, but able to retain paid staff at current levels
Greater difficulty fundraising by clinics in expansion states suggests that funders may perceive less of a need for these clinics
More widespread decreases in the # of volunteer medical positions in clinics in Medicaid expansion states could signal diminished interest in volunteering or, perhaps, may be due to a lessening in volunteer opportunities
Hypothesis 2 Statistically significant differences between Medicaid expansion states and nonexpansion states in:◦ organizational delivery model, billing model, clinic flow,
technology integration, type of data being collected (Hypothesis #2) and
◦ scope of services (Hypothesis #1)
No statistically significant difference in “considering” closure
Discussion of Hypothesis #2 More clinics in Medicaid expansion states are making changes to their clinic operations, which suggests that clinics are attempting to mitigate the environmental uncertainty arising from more of the low-income population gaining coverage
The kinds of changes that “expansion state” clinics are making are MAJOR
Sample
Characteristic2005-2006 National
Survey of Free Clinics
2014 AmeriCares Survey of
Free/Charitable ClinicsMean weekly hours open 18 28Mean annual budget $287,810 $539,278Mean # of paid staff 2.7 7.8Mean # of patients 1,796 1,742Mean # of patient visits 3,217 5,991
Source for 2005-2006 survey data: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.
Limitations Cross sectional study is unable to establish causation Small sample of bigger and better-resourced clinics than the “average” free clinic (Darnell, 2010) Self-reported trends Clinics closing/planning to close less likely to respond
Conclusions Neither the impact nor the response to the Affordable Care Act has been uniform across free/charitable clinics and depends significantly on whether the clinic is located in a Medicaid expansion state
Challenging resource environment for clinics in Medicaid expansion states and non expansion states, but worse in expansion states
Free/charitable clinics are adapting to the new environment
