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Although abortion restrictions will negatively affect the health of all pregnant people, those most affected by this changing landscape will include low-income women and members of marginalized racial and ethnic groups.

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.

Objective: This study evaluates whether gaining Medicaid following the Affordable Care Act (ACA) expansion led to changes in the rate of acute diabetes complications diagnosed in primary care settings, relative to in inpatient, emergency department (ED), or urgent care (UC) settings. Methods: This retrospective cohort study used Medicaid administrative claims data linked to electronic health records for 3767 patients, aged 19 to 64 years, who experienced acute preventable complications of diabetes between 2014 and 2019 diagnosed in inpatient, ED, UC, or primary care settings in the state of Oregon. These patients were classified as either continuously Medicaid-insured or having gained Medicaid. Results: Annual rates of acute complications diagnosed in primary care and inpatient/ED/UC settings increased for both continuously [Adjusted Rate Ratio (aRR) = 2.20, 95% CI = 1.65-2.91] and newly Medicaid-insured patients (aRR = 2.67, 95% CI = 2.05-3.47) after the ACA. Among newly Medicaid-insured, annual rates of abnormal blood glucose diagnosed in primary care settings significantly increased with time while those diagnosed in inpatient/ED/UC decreased (2014 vs 2016 aRR = 3.36, 95% CI = 1.60-7.09). Conclusion: We found a significantly greater rate of abnormal blood glucose diagnosed in primary care clinics among patients who gained Medicaid post-ACA and a corresponding decline in diagnosis in inpatient/ED/UC settings.

Objective: This study evaluates whether patients residing in expansion states have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states following the implementation of the Affordable Care Act (ACA). Methods: This retrospective cohort study uses electronic health records (EHR) from 10,665 non-pregnant patients, aged 19 to 64 years old who were diagnosed with diabetes in 2012 or 2013 from 347 community health centers (CHCs) across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of these periods: pre-ACA: 2012 to 2013, post-ACA: 2014 to 2016, and post-ACA: 2017 to 2019. Acute diabetes-related complications were identified using International Classification Diseases (ICD-9-CM and ICD-10-CM) codes classification and could occur on or after diagnosis of diabetes. We performed difference-in-differences (DID) analysis using a generalized estimating equation to compare the change in rates of acute diabetes complications by year and by Medicaid expansion status. Results: There was a greater increase after year 2015 in visits related to abnormal blood glucose among patient living in Medicaid expansion states than in non-expansion states (2017 DID = 0.041, 95% CI = 0.027-0.056). Although both visits due to any acute diabetes complications and infection-related diabetes complications were higher among patients living in Medicaid expansion states, there was no difference in the trend overtime between expansion and non-expansion states. Conclusion: We found a significantly greater rate of visits for abnormal blood glucose in patients receiving care in expansion states relative to patients in CHCs in non-expansion states starting in 2015. Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit patients with diabetes.

Background Cancer survivors face increased risk for chronic diseases resulting from cancer, preexisting conditions, and cancer treatment. Having an established primary care clinic or health insurance may influence patients’ receipt of recommended preventive care necessary to manage, treat, or diagnose new conditions. This study sought to understand receipt of healthcare in community health centers (CHCs) before and after cancer diagnosis among cancer survivors. We also examined the type of care received and assessed whether being established with a CHC or the type of health insurance affected the use of services. Methods Using electronic health record data and linked cancer registries from 5,649 CHC patients in three states from 2012 through 2018, we obtained monthly rates of primary care and mental health/behavioral health (MHBH) visits and the probability of receipt of care before and after a cancer diagnosis. Results Seventy‐five percent of CHC patients diagnosed with cancer returned to their primary CHC for care within 2‐years of their diagnosis. Among those who returned, there was a sharp increase in primary and MHBH care shortly before their diagnosis. Significantly more primary care (pre: 19.6%, post: 21.9%, p < 0.001) and MHBH care (pre: 1.2%, post: 1.6%, p < 0.001) was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before. Conclusion Use of preventive care for cancer survivors is particularly important. Having an established primary care clinic may help to ensure survivors receive recommended screening and care. In this study on the receipt of preventive healthcare among community health center patients before and after a cancer diagnosis, we found that significantly more primary and mental healthcare was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before.

Background: The prevalence of Post Traumatic Stress Disorder (PTSD) has been rising since the start of the COVID-19 pandemic, and affects females, sexual and gender minorities, and individuals with social risks at higher rates. Objective: This study examines if the prevalence of PTSD increased from 2019 to 2022 among patients who received care in a national network of safety-net, community-based health centers with integrated behavioral health programs that serve patients at high risk for PTSD. Methods: We analyzed electronic health record data from patients with 1 or more behavioral health visits during 2019 to 2022 using repeated cross-sectional data to visualize trends. Change in PTSD prevalence based on the diagnoses associated with each visit from 2019 to 2022 was assessed using a general linear mixed model adjusted for patient-level factors. Results: Over 4 years, 182 419 distinct patients received care for PTSD, with prevalence increasing from 2019 to 2022 (OR = 1.09, 95% CI = 1.08, 1.10). Females (OR = 1.81, 95% CI = 1.78, 1.84), LGBTQIA individuals (OR = 1.29, 95% CI = 1.26, 1.33), gender diverse individuals (OR = 1.36, 95% CI = 1.29, 1.42), and patients who reported 1 or more social determinants of health needs (OR = 1.52, 95% CI = 1.46, 1.57) were more likely to have a diagnosis of PTSD. Conclusions: In a worrying trend, PTSD prevalence has increased among people receiving integrated behavioral health care at community-based health centers, with disparities observed in subpopulations. Continued effort and investment are needed to meet this increasing need in safety-net settings, particularly for those subpopulations observed to have higher prevalence.

Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits. Retrospective interrupted time-series analysis. Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding. There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality. Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Understanding how the COVID-19 pandemic affected cardiovascular disease (CVD) risk monitoring in primary care may inform new approaches for addressing modifiable CVD risks. This study examined how pandemic-driven changes in primary care delivery affected CVD risk management processes. This retrospective study used electronic health record data from patients at 70 primary care community clinics with scheduled appointments from September 1, 2018, to September 30, 2021. Analyses examined associations between appointment type and select care process measures: appointment completion rates, time to appointment, and up-to-date documentation for blood pressure (BP) and hemoglobin A1c (HbA1c). Of 1,179,542 eligible scheduled primary care appointments, completion rates were higher for virtual care (VC) vs in-person appointments (10.7 percentage points [PP]; 95% CI, 10.5-11.0; P < .001). Time to appointment was shorter for VC vs in-person appointments (-3.9 days; 95% CI, -4.1 to -3.7; P < .001). BP documentation was higher for appointments completed pre- vs post pandemic onset (16.2 PP; 95% CI, 16.0-16.5; P < .001) and for appointments completed in person vs VC (54.9 PP; 95% CI, 54.6-55.2; P < .001). HbA1c documentation was higher for completed appointments after pandemic onset vs before (5.9 PP; 95% CI, 5.1-6.7; P < .001) and for completed VC appointments vs in-person appointments (3.9 PP; 95% CI, 3.0-4.7; P < .001). After pandemic onset, appointment completion rates were higher, time to appointment was shorter, HbA1c documentation increased, and BP documentation decreased. Future research should explore the advantages of using VC for CVD risk management while continuing to monitor for unintended consequences.

Youth in foster care have significant unmet health needs. We assessed health needs and health service use among youth in foster care in Oregon using electronic health record data from 258 community health centers and Medicaid enrollment data from 2014–2016. We identified 2,140 youth in foster care and a matched comparison group of 6,304 youth from the same clinics who were not in foster care, and compared the groups on demographic characteristics, health needs, and health service use. Youth in foster care were significantly more likely to have at least one chronic health condition, at least one mental health condition, and at least one mental health service compared with controls. Youth in foster care were significantly less likely to have a primary care visit. Despite significant mental health needs among youth in foster care, few received mental health care; this lack was greater among African American and Hispanic youth.

Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001). The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. ClinicalTrials.gov Identifier: NCT03001713.