Health Center Patients’ Insurance Status and Healthcare Use Prior to Implementation of the Affordable Care Act


      U.S. health centers provide primary and preventive care to underserved populations, including low-income and uninsured patients. The purpose of this study is to examine patterns of publicly funded health center use according to patient insurance status (private, public, none), prior to implementation of the Affordable Care Act.


      National data came from the 2009 Health Center Patient Survey, and were analyzed in 2013. Descriptive analysis of health center patient insurance coverage and health center utilization variables was conducted, followed by adjusted multivariate analysis.


      About 91% of uninsured patients received at least half their annual healthcare visits at a health center, and 86% had at least one usual source of care that included a health center; these rates were not significantly different from those for publicly or privately insured patients. About half of uninsured patients (48%) had long tenures at the health center (≥3 years since first visit), not significantly different from the publicly insured (52%), but lower than the privately insured (63%, p<0.01). Uninsured patients highlighted affordability as the main reason for visiting a health center, whereas insured patients emphasized convenient location and quality of care.


      Insured patients used health centers for the majority of their care, and in similar proportions to their uninsured counterparts. The primary motivation for visiting a health center differed based on insurance type. Future studies should be able to examine whether health center demand across insurance categories follows a similar pattern following the Affordable Care Act insurance coverage expansions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Health Resources and Services Administration. Authorizing legislation of the Health Center Program: Section 330 of the Public Health Service Act (42 USCS § 254b). Accessed March 30, 2015.

      2. Bureau of Primary Health Care. Health center data: 2012 health center impact. 2013. Accessed March 30, 2015.

        • Hadley J.
        • Cunningham P.
        Availability of safety net providers and access to care of uninsured persons.
        Health Serv Res. 2004; 39: 1527-1546
        • Fox J.B.
        • Richards C.L.
        Vital signs: health insurance coverage and health care utilization — United States, 2006–2009 and January–March 2010.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 1448-1454
        • Shen C.
        Determinants of health care decisions: insurance, utilization, and expenditures.
        Rev Econ Stat. 2011; 95 (10.1162/REST-a-00232): 142-153
        • Card D.
        • Dobkin C.
        • Maestas N.
        The impact of nearly universal insurance coverage on health care utilization: evidence from Medicare.
        Am Econ Rev. 2008; 98: 2242-2258
        • Buchmueller T.C.
        • Grumbach K.
        • Kronick R.
        • Kahn J.G.
        The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.
        Med Care Res Rev. 2005; 62: 3-30
        • Freeman J.D.
        • Kadiyala S.
        • Bell J.F.
        • Martin D.P.
        The causal effect of health insurance on utilization and outcomes in adults: a systematic review of US studies.
        Med Care. 2008; 46: 1023-1032
        • Hofer A.N.
        • Abraham J.M.
        • Moscovice I.
        Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization.
        Milbank Q. 2011; 89: 69-89
      3. Agency for Healthcare Research and Quality. 2012 National Healthcare Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality. Published 2013. Accessed March 30, 2015.

        • Shi L.
        • Lebrun-Harris L.A.
        • Daly C.A.
        • et al.
        Reducing disparities in access to primary care and patient satisfaction with care: the role of health centers.
        J Health Care Poor Underserved. 2013; 24: 56-66
        • Shi L.
        • Lebrun L.A.
        • Hung L.M.
        • Zhu J.
        • Tsai J.
        U.S. primary care delivery after the Health Center Growth Initiative: comparison of health centers, hospital outpatient departments, and physicians’ offices.
        J Ambul Care Manage. 2012; 35: 60-74
        • Shi L.
        • Stevens G.D.
        • Politzer R.M.
        Access to care for U.S. health center patients and patients nationally: how do the most vulnerable populations fare?.
        Med Care. 2007; 45: 206-213
      4. Dor A, Pylypchuck Y, Shin P, Rosenbaum S. Uninsured and Medicaid patients’ access to preventive care: comparison of health centers and other primary care providers. Geiger Gibson Program/RCHN Community Health Foundation Research Collaborative. 2008. Accessed March 30, 2015.

        • Ku L.
        • Jones E.
        • Shin P.
        • Byrne F.R.
        • Long S.K.
        Safety-net providers after health care reform: lessons from Massachusetts.
        Arch Intern Med. 2011; 171: 1379-1384
        • Falik M.
        • Needleman J.
        • Wells B.L.
        • Korb J.
        Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers.
        Med Care. 2001; 39: 551-561
      5. CDC. Lack of health insurance coverage and type of coverage: early release of selected estimates based on data from the 2011 National Health Interview Survey. 2012. Accessed March 30, 2015.

      6. CDC. Usual place to go for medical care: early release of selected estimates based on data from the 2011 National Health Interview Survey. 2012. Accessed March 30, 2015.

        • Cantiello J.
        • Fottler M.D.
        • Oetjen D.
        • Zhang N.J.
        Determinants of health insurance coverage rates for young adults: an analytical literature review.
        Adv Health Care Manag. 2011; 11: 185-213
      7. Agency for Healthcare Research and Quality. 2011 National Healthcare Quality and Disparities Reports. Rockville, MD. 2012. Accessed March 30, 2015.

      8. O’Hara B, Caswell K. Health status, health insurance, and medical services utilization: 2010. Current Population Reports. Washington, DC: U.S. Census Bureau. 2013. Accessed March 30, 2015.

      9. Brach C, Chevarley FM. Demographics and health care access and utilization of limited-English-proficient and English-proficient Hispanics. Research Findings No. 28. Agency for Healthcare Research and Quality, Rockville, MD. 2008. Accessed March 30, 2015.

        • Shi L.
        • Lebrun L.A.
        • Zhu J.
        • et al.
        Clinical quality performance in U.S. health centers.
        Health Serv Res. 2012; 47: 2225-2249
        • Lebrun-Harris L.A.
        • Shi L.
        • Zhu J.
        • Burke M.T.
        • Sripipatana A.
        • Ngo-Metzger Q.
        Effects of patient-centered medical home attributes on patients ’ perceptions of quality in federally supported health centers.
        Ann Fam Med. 2013; 11: 508-516
        • Shi L.
        • Lebrun-Harris L.A.
        • Parasuraman S.R.
        • Zhu J.
        • Ngo-Metzger Q.
        The quality of primary care experienced by health center patients.
        J Am Board Fam Med. 2013; 26: 768-777