Changes in geographic access to community health centers for - PowerPoint PPT Presentation

Changes in geographic access to community health centers for low-income, nonelderly adults after increases in Health Center Program funding Leigh Evans, MPH and M. Patricia Fabian, ScD June 24, 2017 AcademyHealth Disparities Interest Group Meeting New Orleans, LA Boston University School of Public Health

Boston University Slideshow Title Goes Here BACKGROUND Boston University School of Public Health

Community Health Centers (CHCs) ensure access to primary care for low-income, nonelderly adults Boston University Slideshow Title Goes Here  CHCs provide primary care to all regardless of ability to pay  Located in underserved areas  History of bipartisan support  Reduce health disparities Boston University School of Public Health

Health Center Program funding increases Boston University Slideshow Title Goes Here  $2 billion from American Recovery and Reinvestment (Stimulus) Act 2009  $11 billion from Affordable Care Act 2010-2015 Boston University School of Public Health

Considering geographic access Boston University Slideshow Title Goes Here  Relevant to number and location of new delivery sites  Limited research on geographic access (accessibility)  Linked to patient perceptions of access, utilization, quality of care, and outcomes  Research gap : Effect of policies on geographic access to CHCs for low-income, nonelderly adults  Geographic access  CHC accessibility Boston University School of Public Health

Research objectives Boston University Slideshow Title Goes Here 1. Describe location of CHC delivery sites in three Southern U.S. states before and after Health Center Program funding increases 2. Estimate CHC accessibility for low-income, nonelderly adults using geographic information system (GIS)-based methods in 2008 and 2016 3. Examine changes in CHC accessibility between 2008 and 2016 Boston University School of Public Health

Boston University Slideshow Title Goes Here METHODS Boston University School of Public Health

Methods Boston University Slideshow Title Goes Here  Study design : retrospective, repeated measures analysis using publicly available data  Study area : Arkansas, Louisiana, Mississippi  Contiguous  High proportion of low-income, nonelderly adults  People in the South are prone to health disparities  Differed in Medicaid expansion decisions Boston University School of Public Health

Methods Boston University Slideshow Title Goes Here  Data:  CHC delivery sites from HRSA Data Warehouse  Jan 1966-Sept 2016  Adults ages 18-64 under 200% federal poverty level from American Community Survey  5-year estimates 2011-2015  n = 2,444,408  Shapefiles from U.S. Census 2010  Census tracts: n = 2,483 Boston University School of Public Health

Methods Boston University Slideshow Title Goes Here  Used two-step floating catchment area method (Luo and Wang 2003)  Combines two approaches: drive time distance and provider- to-population ratios  Resulting value is a ratio of CHC delivery sites per potential users in a census tract Boston University School of Public Health

Boston University Slideshow Title Goes Here RESULTS Boston University School of Public Health

Changes in number of CHC delivery sites Boston University Slideshow Title Goes Here Across 3 states Pre Post % change # CHC delivery sites 150 332 121% Arkansas Pre Post % change # CHC delivery sites 40 95 138% Louisiana # CHC delivery sites 40 125 213% Mississippi # CHC delivery sites 70 112 60% Boston University School of Public Health

CHC delivery sites and population density (ppl/square mile) by census tract- Louisiana 2008 and 2016 2008 2016 Boston University Slideshow Title Goes Here 40 delivery sites 125 delivery sites Boston University School of Public Health

Changes in geographic access for low- income, nonelderly adults (2008 to 2016) Boston University Slideshow Title Goes Here Arkansas (n=686) Pre Post % change CHC accessibility (CHCs/10,000 low-income, 0.10 (1.38) 0.94 (1.89) 840% nonelderly adults) Louisiana (n=1,136) CHC accessibility 0.26 (0.75) 1.32 (0.97) 408% Mississippi (n=661) CHC accessibility 0.83 (0.97) 1.49 (1.08) 80% Boston University School of Public Health

CHC accessibility for low-income, nonelderly adults (CHCs/10,000 ppl) by census tract- Arkansas 2008 and 2016 Boston University Slideshow Title Goes Here 2008 2016 Boston University School of Public Health

CHC accessibility for low-income, nonelderly adults (CHCs/10,000 ppl) by census tract- Mississippi 2008 and 2016 2008 2016 Boston University Slideshow Title Goes Here Boston University School of Public Health

Limitations Boston University Slideshow Title Goes Here  Assumptions in methods  Drive time distance  Stack population at population-weighted centroids  No crossing state boundaries  Lack data on CHC capacity  Potential access vs. perceived access or realized access (utilization), and link to health outcomes Boston University School of Public Health

Summary and implications Boston University Slideshow Title Goes Here  Geographic access increased across all 3 states  Mississippi had the highest CHC accessibility ratios  Measuring and mapping geographic access to CHCs can show where changes are happening  Considering geographic access when locating new CHC delivery sites can promote equity in access to care for low-income Americans Boston University School of Public Health

Boston University Slideshow Title Goes Here Boston University School of Public Health

Acknowledgements Boston University Slideshow Title Goes Here  Martin Charns, DBA  Howard Cabral, PhD  Victoria Parker, DBA  David Jones, PhD  Thomas Evans, LSLS Boston University School of Public Health

Boston University Slideshow Title Goes Here Thank you!! Leigh Evans leighe@bu.edu Boston University School of Public Health

New CHC delivery sites by year Added CHC delivery sites by year- 1966-2015 Boston University Slideshow Title Goes Here 1600 1493 1400 1200 933 1000 721 800 674 600 479 400 308 203 122 200 54 59 37 26 7 0 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011 * Data source: Health Resources and Services Administration; HRSA Data Warehouse Boston University School of Public Health

Estimating CHC accessibility Boston University Slideshow Title Goes Here  Two-step floating catchment area method (Luo and Wang) 1. Create catchments around each CHC and capture population within those catchments  ratio of potential patients using CHC 2. Create catchments around each census tract and sum ratios of all CHCs within the tract’s catchment  Resulting value is the number of CHCs per potential user in a tract  It is a ratio Boston University School of Public Health

Presentation Title 6/24/2017 24 Two-step floating catchment area method Step 1 Boston University Slideshow Title Goes Here 1/20,000 1/12,000 1/8,000 1/15,000 Boston University School of Public Health

Presentation Title 6/24/2017 25 Two-step floating catchment area method Step 2 Boston University Slideshow Title Goes Here Sum the ratios from step 1 for all CHCs that fall within step 2 catchment Boston University School of Public Health

Census tracts lacking geographic access Boston University Slideshow Title Goes Here Arkansas (n=686) Pre Post % change Census tracts with 0 CHCs/10,000 low-income, 275 (40%) 101 (15%) -63% nonelderly adults Louisiana (n=1,136) CHC accessibility 231 (20%) 46 (4%) -80% Mississippi (n=661) CHC accessibility 114 (17%) 30 (5%) -74% Reductions in geographic access disparities Boston University School of Public Health

In 2015, the majority of the uninsured are low-income adults, and more than half are people of color. Boston University Slideshow Title Goes Here Family Income Parent Status Race Asian/Nativ e Hawaiian (%FPL) Other or Pacific 3% Islander 5% 400%+ Children <100% FPL 15% FPL 19% 26% White Hispani non- Childless 200-399% Parents Adults c Hispanic 32% FPL 100-199% 26% 45% 59% FPL 28% 27% Black 15% Total = 28.5 Million Uninsured NOTES: The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $19,078 in 2015. Data may not total 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of the 2016 ASEC Supplement to the CPS. Boston University School of Public Health

In 2016, an estimated 2.6 million nonelderly adults fall into the coverage gap, most of whom reside in the South. Distribution By Geographic Region: Boston University Slideshow Title Goes Here Total = 2.6 Million in the Coverage Gap South 91% Midwest 6% Northeast <1% West 3% Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey data. Boston University School of Public Health

Policy context Boston University Slideshow Title Goes Here  Affordable Care Act extended health coverage to many low-income Americans but left many uninsured  Particularly those in states that did not expand Medicaid  23 million Americans stand to lose their health coverage with the proposed American Health Care Act  Coverage notwithstanding, many Americans live in areas where primary care resources are lacking Boston University School of Public Health