Article

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.
The Journal of Rural Health (Impact Factor: 1.77). 02/2009; 25(1):8-16. DOI: 10.1111/j.1748-0361.2009.00193.x
Source: PubMed

ABSTRACT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities.
We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence.
We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits.
Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22).
The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

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    • "In 2010 the Affordable Care Act (ACA) appropriated an additional $11 billion over five years to establish CHCs as one of the pillars of health care reform—infrastructure intended to help serve the millions of Americans projected to gain health insurance under its provisions. Part of the rationale for the expansion of CHCs relies on a widely-held belief that they improve access to primary care and curb health care cost increases (Cunningham 2006, Falik et al. 2006, Rust et al. 2009, Hawkins and Schwartz 2003). "
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    ABSTRACT: This paper uses the rollout of the first Community Health Centers (CHCs) to study the longer-term health effects of increasing access to primary care. Within ten years of their establishment, CHCs are associated with a reduction in age-adjusted mortality rates of almost 2 percent among those 50 and older. The implied 7 to 13 percent decrease in one-year mortality risk among beneficiaries amounts to 20 to 40 percent of the 1966 poor/non-poor mortality gap for this age group. Large effects for those 65 and older suggest that increased access to primary care has longer-term benefits, even for populations with near universal health insurance. the NICHD (T32 HD0007339) as a UM Population Studies Center Trainee. We are grateful to Doug Almond, Hilary Hoynes, and Diane Schanzenbach for sharing the Regional Economic Information System (REIS) data for the period of 1959 to 1978; Amy Finkelstein for sharing the American Hospital Association (AHA) Annual Survey data from 1948 to 1974; Jean Roth for sharing the AHA data from 1976 to 1990; Cynthia Severt and the University of Wisconsin DISC for helping us locate and compile the OEO survey data; and Cheryl Sutherland and Jeffrey Hackett from NORC for helping us locate the restricted geographic identifiers in the SHSUE. We are also grateful for helpful comments from
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