1. How are free & charitable clinics faring under the Affordable Care Act? JULIE DARNELL, ASSOCIATE PROFESSOR, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF ILLINOIS AT CHICAGO LINDSAY O’BRIEN, ASSOCIATE DIRECTOR, U.S. PROGRAMS, AMERICARES 143 RD APHA ANNUAL MEETING & EXPO, NOVEMBER 2, 2015, CHICAGO, IL We gratefully acknowledge support from the General Electric Foundation.

2. What are free & charitable clinics? bills third-party payer 501(c)(3) entities Target care to uninsured and/or underserved patients Provide medical, dental, mental/behavioral health, medications Utilize volunteers Don’t bill third-party payers Provides all goods and services at no charge, but may request donations Provides goods & services for a fee Charitable Clinic Free Clinic Hybrid Clinic

3. Scope of the Free Clinic Sector ~ 1,000 free clinics in 2005-2006 Collectively served nearly 2 million mostly uninsured patients annually Provided 3.5 million medical and dental visits Source: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.

4. Newly Insured 22.8 million gained coverage between 9/2013 to 2/2015 ◦9.6 million in employer-sponsored plans ◦6.5 million in Medicaid plans ◦4.1 million in individual marketplace ◦1.2 million nonmarketplace individual plans ◦1.5 million in other plans 5.9 million lost coverage 16.9 million (net) newly insured Source: Carman, K. G. Trends in Health Insurance Enrollment, 2013-15, Health Affairs, v. 34, no. 6, June 2015, p. 1044-1048. [RAND STUDY]

5. Uninsured Source: Congressional Budget Office. 2015. Insurance Coverage Provisions of the Affordable Care Act— CBO’s March 2015 Baseline.

6. NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/ Adopted (31 States including DC) Adoption Under Discussion (1 State) Not Adopting At This Time (19 States) Current Status of Medicaid Expansion Decisions

7. Research Question and Hypotheses Research Question: How are free & charitable clinics faring under the Affordable Care Act? Hypothesis 1: Clinics located in states that have expanded Medicaid are faring worse than clinics located in non- expansion states. Hypothesis 2: Clinics located in states that have expanded Medicaid are more likely to have made changes to their clinic operations than clinics in non- expansion states.

8. AmeriCares Emergency response and global health organization whose mission is to improve health and save lives in communities affected by disaster and in those with limited resources Model : ◦Product donations from more than 200 corporations ◦Service delivery through local health care partners ◦Leverage: for every $1 donated, AmeriCares provides $20 in aid

9. METHODS

10. Survey Who: Free and charitable clinic partners of AmeriCares What: ◦Organizational characteristics ◦Levels of funding and in-kind support ◦Fundraising efforts ◦Staffing and volunteer levels ◦Changes to operations (clinic, patients, services) When: October-November 2014 How: Web-based survey

11. RESULTS

12. Response Rate 156 out of 355 eligible clinic partners (43.9%) CharacteristicOdds ratio95% CIp-value Weekly hours.992.979, 1.005.223 Budget.999.999, 1.048 # Volunteers.999.998, 1.002.987 # Paid staff1.050.998, 1.104.058 # Patients.999.999, 1.000.069 # Patient visits1.000.999, 1.000.346 Medicaid expansion state1.421.901, 2.241.130 Logistic regression of non-response Notes: dependent variable = non-response to survey; n=339; CI=confidence interval.

13. AmeriCares Sample Characteristics CharacteristicTotal (n=355) Respondent (n=156) Nonrespondent (n=199) p-value Mean weekly hours open (n=341) 292830.285 Mean annual budget (n=347) $620,929$539,278$684,576.263 Mean # of volunteers (n=345) 130 129.939 Mean # of paid staff (n=340) 7.77.87.7.906 Mean # of patients (n=347) 1,9001,7422,024.278 Mean # of patient visits (n=347) 6,0075,9916,019.976 % in Medicaid expansion state (n=355) 37.240.434.7.269 Notes: We tested differences in means between respondents and nonrespondents with the t-test and differences in categorical variables with the chi-square test. Tests of significance were two-tailed. We performed statistical analyses with Stata (ver 14).

14. Hypothesis #1: Faring Worse in Expansion States

15. Trends in Funding: Fundraising p-value=.009 Differences are statistically significant.

16. Trends in Funding p-value=.896 Differences are NOT statistically significant. p-value=.710

17. Trends in In-Kind Support p-value=.031 Differences are statistically significant.

18. Trends in Staffing: Paid Positions p-value=.102 Differences are NOT statistically significant. p-value=.053

19. Trends in Staffing: Volunteer Medical Positions p-value=.018 Differences are statistically significant. p-value=.035

20. Trends in Scope of Services p-value=.000 Differences are statistically significant.

21. Trends in Patient Volume: Patients & Visits p-value=.005 Differences are statistically significant. p-value=.024

22. Hypothesis #2: More Organizational Changes in Expansion States

23. Operational Changes: Organizational Delivery Model p-value=.000 Differences are statistically significant.

24. Operational Changes: Billing Model p-value=.018 Differences are statistically significant.

25. Operational Changes: Clinic Flow p-value=.000 Differences are statistically significant.

26. Operational Changes: Technology Integration p-value=.000 Differences are statistically significant.

27. Operational Changes: Type of Data Collected p-value=.001 Differences are statistically significant.

28. Organizational Changes: Closure p-value=.290 Differences are not statistically significant. Of the 8% (13 clinics) that “considered closing,” none reported actually planning to close

29. DISCUSSION

30. Hypothesis 1 Statistically significant differences between Medicaid expansion and non-expansion states in: ◦fundraising, in-kind support, # of volunteer medical positions, # of patients, # of patient visits No statistically significant differences in funding levels or in # of paid positions Statistically significant differences in scope of services opposite hypothesized

31. Discussion of Hypothesis #1 Greater resource constraints facing clinics in expansion states, but able to retain paid staff at current levels Greater difficulty fundraising by clinics in expansion states suggests that funders may perceive less of a need for these clinics More widespread decreases in the # of volunteer medical positions in clinics in Medicaid expansion states could signal diminished interest in volunteering or, perhaps, may be due to a lessening in volunteer opportunities

32. Hypothesis 2 Statistically significant differences between Medicaid expansion states and nonexpansion states in: ◦organizational delivery model, billing model, clinic flow, technology integration, type of data being collected (Hypothesis #2) and ◦scope of services (Hypothesis #1) No statistically significant difference in “considering” closure

33. Discussion of Hypothesis #2 More clinics in Medicaid expansion states are making changes to their clinic operations, which suggests that clinics are attempting to mitigate the environmental uncertainty arising from more of the low-income population gaining coverage The kinds of changes that “expansion state” clinics are making are MAJOR

34. Sample Characteristic 2005-2006 National Survey of Free Clinics 2014 AmeriCares Survey of Free/Charitable Clinics Mean weekly hours open1828 Mean annual budget$287,810$539,278 Mean # of paid staff2.77.8 Mean # of patients1,7961,742 Mean # of patient visits3,2175,991 Source for 2005-2006 survey data: Darnell, J. S. (2010). Free clinics in the United States: a nationwide survey. Archives of Internal Medicine, 170(11), 946-953.

35. Limitations Cross sectional study is unable to establish causation Small sample of bigger and better-resourced clinics than the “average” free clinic (Darnell, 2010) Self-reported trends Clinics closing/planning to close less likely to respond

36. Conclusions Neither the impact nor the response to the Affordable Care Act has been uniform across free/charitable clinics and depends significantly on whether the clinic is located in a Medicaid expansion state Challenging resource environment for clinics in Medicaid expansion states and non expansion states, but worse in expansion states Free/charitable clinics are adapting to the new environment

37. Thank You! JULIE DARNELL, JDARNELL@UIC.EDUJDARNELL@UIC.EDU LINDSAY OBRIEN, LOBRIEN@AMERICARES.ORGLOBRIEN@AMERICARES.ORG