This piece was originally published in the Oregon Academy of Family Physicians Spring 2017 magazine. Reprinted with permission from the authors.

After the passage of the Affordable Care Act (ACA), I was elated to see many patients on my panel gain access to health insurance and get the healthcare that was unaffordable and inaccessible for years. I remember the 25-year-old with cystic fibrosis who was so excited to tell me about his new job – he had gained coverage on his parents’ plan which helped him improve his overall health and get a better job (with great coverage!). I rejoiced when a 55-year-old grandmother was finally able to receive comprehensive treatment for her depression and return to volunteering at her grandchild’s school, and it was heartwarming to hear from the 40-year-old single mother who told me that re-gaining Medicaid relieved her worries about staying healthy to raise her boys. A decade ago, she brought me to tears when after losing her coverage, she asked me, “how am I going to raise my children if something happens to me and I cannot get health care?” 

Across Oregon, primary care teams are seeing the impact of health insurance expansions and other ACA policy reforms. Since the ACA took effect, 95 percent of all Oregonians now have health care coverage, and Oregon’s uninsured rate has dropped from 17 to 5 percent.¹ Many of us are communicating with policy makers and community leaders about further changes we believe are necessary to improve access to healthcare and improved population health. Coupled with our personal experiences and patients’ stories from healthcare’s front lines, Oregon’s family medicine community is studying the impact of policy change on patients’ and families’ access to care.

In partnership with OCHIN (www.ochin.org) and the amazing community laboratory OCHIN has built, researchers in the Oregon Health & Science University (OHSU) Department of Family Medicine discovered:

• Individuals who gained Medicaid in Oregon’s 2008 Medicaid expansions, also known as the “Oregon Experiment,” had an increased rate of primary care visits and preventive services, as compared to those who remained uninsured.^2,3 
• A higher percentage of Oregon community health center (CHC) patients who gained Medicaid quit smoking compared to those who remained uninsured.⁴
• After the ACA Medicaid expansions were implemented in 2014, CHCs in Medicaid expansions states saw a dramatic drop in the number of uninsured patients seeking primary care services, while CHCs in states opting out of the expansion continued to see high rates of uninsured patients.^5,6
• Over time, patients with partial or no health insurance coverage are less likely to receive preventive services compared with those who have continuous coverage; with no evidence of a dose-response relationship (i.e., more time covered is not necessarily better than less time covered if the coverage is not 100% continuous).⁷
• The percent of a clinic’s patients with continuous health insurance influences how well the clinic performs on quality metrics (e.g., A1c testing, influenza immunizations, and lipid screening for diabetics); thus, this information should be factored into an adjusted performance rating and all efforts should be made to increase insurance rates in the population.⁸
• Even when uninsured patients are able to access primary care, they are less likely than insured patients to be able to access many preventive services and more likely to be overdue for recommended services. ^9-11
• There is a causal link between coverage for parents and their children. A child with an uninsured parent is less likely to have health insurance, even if their child qualifies for child-only coverage.^12,13  
• Family income is the characteristic most strongly associated with a family’s lack of full-year health insurance.¹⁴

As someone with a history of being vocal and passionate about the need for drastic health policy reforms, I do not subscribe to health insurance as the complete solution to fixing our unsustainable healthcare system.¹⁵ I admit to being a skeptic about the ACA and some important features it was lacking, such as strict cost containment and a public insurance option. However, as we continue the work to discover the best cures for the American epidemic of “uninsurance” and finding new treatments for our nation’s “inequitable access to care” disease, there is increasing evidence that the ACA health insurance expansions are a step forward. 

So, where do we go from here? I’m ready to move beyond asking the question about whether or not health insurance matters. (For those not ready to move beyond this point, consider asking them the following two questions: 1. Are you willing to drop your health insurance policy immediately and go without health insurance indefinitely? 2. Are you willing to enroll in a study where you are randomized to either receive health insurance or go without health insurance forever? If the answer to either or both of these questions is “no,” then we can keep moving forward toward insuring every person in this country). 

I assert that health insurance matters and so does primary care. The combination of insurance and a usual source of care (USC) is associated with the highest rates of preventive health care, compared to having either insurance or a USC or neither one.^16,17 We have important work ahead of us to continue building the 21^st century community classrooms that will inspire young people to choose careers in primary care and the community laboratories to improve our ability to transform primary care delivery, to assess the impact of policy changes on patients and communities,¹⁸ and to discover how to best organize and pay for primary care in order to achieve the quadruple aim.¹⁹

Rather than repealing the ACA and going back to an era where patients lose health insurance coverage, I’d like to see continued momentum towards transforming the healthcare system and partnering with communities to eliminate health disparities and improve population health. This momentum comes from us as advocates. Our experience matters, our work makes a difference, and our stories amplify the voices of those in our communities who are afraid to speak up or who are not being heard. It is up to us to continue sharing these powerful stories and our experiences and to keep moving forward.

References

1. 95PERCENTOREGON. Learn what the ACA means for Oregonians. 2017; http://www.95percentoregon.com/.
2. DeVoe JE, Marino M, Gold R, et al. Community Health Center Use After Oregon’s Randomized Medicaid Experiment. Ann Fam Med. 2015;13(4):312-320.
3. Marino M, Bailey S, Gold R, et al. Receipt of Preventive Services after Oregon’s Randomized Medicaid Experiment. Am J PrevMed. 2015;50(2):161-170.
4. Bailey SR, Hoopes MJ, Marino M, et al. Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study. J Gen Intern Med. 2016;31(10):1198-1205.
5. Angier H, Hoopes M, Gold R, et al. An early look at rates of uninsured safety net clinic visits after the Affordable Care Act. Ann Fam Med. 2015;13(1):10-16.
6. Hoopes MJ, Angier H, Gold R, et al. Utilization of Community Health Centers in Medicaid Expansion and Nonexpansion States, 2013-2014. J Ambul Care Manage. 2016;39(4):290-298.
7. Gold R, DeVoe JE, McIntire PJ, Puro JE, Chauvie SL, Shah AR. Receipt of diabetes preventive care among safety net patients associated with differing levels of insurance coverage. J Am Board Fam Med. 2012;25(1):42-49.
8. Bailey SR, O’Malley JP, Gold R, Heintzman J, Likumahuwa S, DeVoe JE. Diabetes care quality is highly correlated with patient panel characteristics. J Am Board Fam Med. 2013;26(6):669-679.
9. Gold R, Bailey SR, O’Malley JP, et al. Estimating Demand for Care After a Medicaid Expansion: Lessons From Oregon. J Ambul Care Manage. 2014;37(4):282-292.
10. Heintzman J, Marino M, Hoopes M, et al. Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients. Prev Med. 2014;67:306-310.
11. Bailey SR, O’Malley JP, Gold R, Heintzman J, Marino M, DeVoe JE. Receipt of Diabetes Preventive Services Differs by Insurance Status at Visit. Am J PrevMed. 2015;48(2):229-233.
12. DeVoe JE, Marino M, Angier H, et al. Effect of Expanding Medicaid for Parents on Children’s Health Insurance Coverage Lessons From the Oregon Experiment. JAMA Ped. 2015;169(1):e143145.
13. DeVoe JE, Crawford C, Angier H, et al. The Association Between Medicaid Coverage for Children and Parents Persists: 2002-2010. Matern Child Health J. 2015;Epub ahead of print.
14. Angier H, DeVoe JE, Tillotson C, Wallace L, Gold R. Trends in health insurance status of US children and their parents, 1998-2008. Matern Child Health J. 2013;17(9):1550-1558.
15. DeVoe JE. The unsustainable US health care system: a blueprint for change. Ann Fam Med. 2008;6(3):263-266.
16. DeVoe JE, Tillotson CJ, Wallace LS, Lesko SE, Pandhi N. Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counseling. Matern Child Health J. 2012;16(2):306-315.
17. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care. Am J Public Health. 2003;93(5):786-791.
18. DeVoe JE, Likumahuwa-Ackman S, Shannon J, Steiner Hayward E. Creating 21st-Century Laboratories and Classrooms for Improving Population Health: A Call to Action for Academic Medical Centers. Acad Med. 2016.
19. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.