Diabetes and Hypertension Prevention and Control in Community Health Centers: Impact of the Affordable Care Act

Abstract

Access to care significantly improved following the implementation of the Patient Protection and Affordable Care Act. Since its implementation, the number of uninsured Americans has significantly decreased. Medicaid expansion played an important role in community health centers, who serve historically marginalized populations, leading to increased clinic revenue, and improved access to care. As the continuous Medicaid enrollment provision established during the pandemic ended, and states have to make decisions about their program eligibility, exploring the impact of Medicaid expansion on the detection, and management of hypertension and diabetes could inform these decisions. We summarized the effect of Medicaid expansion on community health centers and their patients specific to hypertension and diabetes from existing literature. These studies suggest the beneficial impact of the Affordable Care Act and acquiring insurance on diabetes and hypertension disease detection, treatment, and control for patients receiving care in community health centers. Overall, these studies suggest the clear importance of health insurance coverage, and notably insurance stability, on diabetes and hypertension control.

Introduction

Following the enactment of the Patient Protection and Affordable Care Act (ACA) in 2010, millions of adults acquired health insurance. ¹ Over a decade ago, the ACA was enacted with the goal of expanding coverage to all US citizens and legal residents. ² The ACA expanded health insurance coverage options through state-based Medicaid eligibility expansion to persons ≤138% of the federal poverty level (FPL), young adult coverage, and a health insurance marketplace with subsidies for qualified individuals to purchase private coverage. Since its implementation, the number of uninsured Americans decreased from 46.5 million in 2010 to 27.5 million in 2021. ¹ Additionally, the ACA required Medicaid and private insurance plans to cover recommended preventive services without any patient cost-sharing including services recommended by the U.S. Preventive Services Task Force (USPSTF) and insurance access for individuals with pre-existing conditions. ² Individuals without insurance continued to incur out of pocket costs for preventive and other chronic condition services, including hypertension and diabetes screening, and costs incurred from treatment of these conditions once diagnosed.

Community health centers (CHCs) that serve historically marginalized populations significantly benefited from the ACA, particularly Medicaid expansion.^3,4 CHCs annually deliver care to 30 million patients regardless of health insurance status.^3,4 Using a sliding payment scale, CHCs serve: 1 in 5 Medicaid beneficiaries; 1 in 3 uninsured persons; 1 in 3 individuals living below the federal poverty level (FPL); and 1 in 5 rural Americans. ³ The majority (65%) of CHC patients are members of racial/ethnic minority groups. ³ In addition, CHC patients are more likely to have chronic diseases in general, hypertension and diabetes specifically, the most common chronic diseases among adults in United States. ³

Although CHCs have been shown to deliver high quality care and reduce disparities by facilitating access to care, their patients have higher rates of chronic diseases than those seen in private practices. ³ The prevalence of hypertension (45%) and out-of-control diabetes (A1c > 9: 21%) across CHCs in the US is higher than that of non-CHCs (32% and 19%, respectively), and far from the HealthyPeople 2030 targets (42.6% and 11.6%, respectively^5,6). Medicaid expansion played an important role in CHCs leading to increased clinic revenue and improved access to care. ⁴ As the continuous Medicaid enrollment provision established during the COVID-19 pandemic ended, exploring the impact of Medicaid expansion on the detection and management of hypertension and diabetes could inform states decisions on program eligibility. Therefore, this work summarizes the effect of Medicaid expansion on CHCs and their patients specific to hypertension and diabetes from existing literature. Publications selected for this commentary were restricted to CHCs settings, diabetes and/or hypertension outcomes, and Medicaid expansion or insurance acquisition as a result of the Affordable Care Act.

Diabetes and Hypertension Screening

Only a few studies have assessed changes in cardiovascular preventive screenings following the ACA and Medicaid expansion.^{7 -9} Results from these studies showed improvement in glycemic screening but observed no change in blood pressure screening. Among patients with diabetes, there was a significant increase in screening for hemoglobin A1c in both expansion and non-expansion states, with a somewhat greater rise in expansion states. ⁹ This was also true among certain subpopulations including patients with pre-diabetes and cancer survivors. ⁷ Unsurprisingly, rates of hypertension screening did not change as blood pressure screening is already high (>90%) and typically measured at almost every visit. In contrast, hemoglobin A1c tests are not systematically conducted during a visit and need to be ordered with a follow-up test to a laboratory for blood draw. These studies suggest that acquiring insurance through the ACA led to improvement in diabetes screening among those with limited economic resources.

Diabetes and Hypertension Diagnosis

A few studies assessed change in diagnosis rates of hypertension and diabetes.^{10 -12} Regarding hypertension, one study showed a small increase (7%) in hypertension diagnosis rates among patients receiving care in states that expanded Medicaid and a small decline (6%) in hypertension diagnoses in states that did not expand. ¹⁰ Another study showed that the time to diagnosis was shortest among those who acquired insurance post-ACA relative to other insurance patterns (eg, continuously insured). ¹² For diabetes, a few studies showed a significant increase in diabetes diagnosis by more than 25% among all patients served by CHCs post-ACA (both expansion and non-expansion states).^10,11 Notably, Hispanic and non-Hispanic black CHC patients experienced the largest increase in diagnosis of diabetes following the ACA. ¹¹ The rise in diabetes diagnosis may have been associated with the increase in number of visits to a healthcare provider and diabetes screening following acquiring health insurance.

Diabetes and Hypertension Treatment

Although there was no ACA provision that specifically targeted diabetes and hypertension treatment, health insurance can greatly reduce barriers by increasing access to ongoing care and prescription drug coverage. That said, CHCs provide care for all patients regardless insurance coverage, but on a sliding scale. Additionally, many CHCs patients also have access to medications at lower cost via the 340B Drug Discount Program. ¹³ Under this program, qualified healthcare systems and providers can purchase and dispense medications at a significant discount which greatly reduces the out-of-pocket cost.

Very few studies have evaluated the change in medications prescribed or overall treatment of hypertension or diabetes following the implementation of ACA. Regarding hypertension treatment, evidence shows that most patients with hypertension are prescribed anti-hypertensive medication (varying between >70% and 91%).^12,14 CHC patients who continued to be uninsured following the ACA where less likely to have medications ordered than those who acquired insurance (77.7% vs 91.0%, respectively); though a pre-ACA study found no difference in prescription rates by insurance status. ¹⁴ Among CHC patients with diabetes, one study showed that acquiring insurance led to a greater increase in medication orders post-ACA relative to those continuously insured. ¹⁵ This pattern of findings suggests that patients served by CHCs are appropriately prescribed medications for their chronic diseases; but also that insurance improves access to medication. These studies did not evaluate whether medications were filled or prescribed dosages were followed by patients as the information was based on prescription orders or self-report. Future research is needed to evaluate whether barriers to medication adherence were removed or reduced by increasing access to care through health insurance.

Diabetes and Hypertension Control

There is evidence that post-ACA, patients receiving care in CHCs showed improvement in both hypertension and diabetes control.^{14 -21} Specifically, clinic level quality metrics demonstrated a greater improvement in the percent of patients with controlled diabetes and hypertension in CHCs located in expansion relative to CHCs in non-expansion states following the ACA. ¹⁶ Similarly, patients who acquired insurance post-ACA were more likely to lower their blood pressure and HbA1c than those remaining uninsured. ¹⁵ Additionally, acquiring insurance (whether or not associated with ACA) and insurance stability was also associated with diabetes control, blood pressure control, and severe hypertension control (Systolic ≥150 mmHg or Diastolic ≥100 mmHg).^14,17,18 A few studies have shown greater improvement in hypertension and diabetes control for black and Hispanic patients residing in expansion states relative to non-expansion states.^16,19 While acquiring insurance was linked to reductions in HbA1c levels among Hispanic patients, insurance instability was associated with greater odds of uncontrolled hypertension among black patients. ²¹ One study also noted that acquiring insurance led to greater hypertension control among patients living in the most deprived neighborhoods relative to those residing in less deprived areas. ²⁰ Overall, these findings suggest the clear importance of health insurance coverage, and notably insurance stability, on diabetes and hypertension control.

Conclusion

These studies suggest the beneficial impact of the ACA and acquiring insurance on diabetes and hypertension disease detection, treatment, and control for patients receiving care in CHCs. Acquiring insurance through healthcare reform such as the ACA led to improvement in diabetes screening and diagnosis and diabetes and hypertension treatment and control among those with limited economic resources. One exception was hypertension screening and diagnosis, with similar results found when comparing non-expansion and expansion states and pre- and post-ACA. Blood pressure measurements are routinely completed at clinic visits in CHCs, with hypertension likely to be detected and diagnosed promptly regardless of health insurance access. Removing financial barriers associated with healthcare out-of-pocket costs for visits and associated screening or test appears to be important to facilitate diabetes screening and diagnosis.

However potential challenges remain, with continued efforts needed for CHCs to move toward achieving HealthyPeople 2030 targets. Uptake of telemedicine visits during the pandemic made routine blood pressure screenings and hypertension diagnosis challenging as most patients do not own home blood pressure devices. While telemedicine may facilitate access to care by reducing transportation barriers, having to take time off work, or finding childcare, it may also drive care gaps especially among socially and economically disadvantaged patients.

Also critical for cardiovascular health among CHCs patients is insurance stability. During the COVID-19 pandemic, Congress included a provision within the Families First Coronavirus Response Act to keep people continuously enrolled through the end of the public health emergency; this provision ended March 31, 2023. The termination of this provision has led to Medicaid disenrollment and is expected to result in churning from Medicaid to other coverage or uninsurance and to increased premiums for private insurance. ²² The resulting loss in coverage could lead to fewer resources and lower staffing rates in CHCs associated with the loss in reimbursement. Additionally, there have been recent challenges to coverage for USPTF recommended prevention recommendations, which includes screening for diabetes, pre-diabetes, and hypertension. ²³ These changes will have a greater negative impact on people with lower incomes, many receiving care in CHCs. ²⁴ It is unclear what impact these changes will have on patients’ ability to manage and control their cardiovascular diseases as CHCs will continue to care for these patients regardless of their insurance status or ability to pay. A few states (CA, IL, MA, OR) have implemented (or implementing) policies to improve insurance access to their citizens; including universal health care coverage or expanding Medicaid eligibility to undocumented immigrants. Understanding the impact of these policy expansions on access to care, health outcomes, clinical quality metrics and resources as well as their cost effectiveness in reducing healthcare expenditures will be important to inform insurance expansion policies.